The vanishing endometrioma: the intriguing impact of pregnancy on small endometriotic ovarian cysts

Untangling the independent effect of endometriosis, adenomyosis, and ART-related factors on maternal, placental, fetal, and neonatal adverse outcomes: results from a systematic review and meta-analysis

BACKGROUND

Women with endometriosis may constitute a group at a particularly increased risk of pregnancy-related complications. Furthermore, women selected for assisted reproductive technology (ART) are exposed to additional endocrinological and embryological factors that have been associated with adverse pregnancy outcomes.

OBJECTIVE AND RATIONALE

This study aimed to investigate the independent effect of endometriosis, adenomyosis, and various ART-related factors on adverse maternal, placental, fetal, and neonatal outcomes.

SEARCH METHODS

Published randomized controlled trials, cohort studies, and case-control studies were considered eligible. PubMed, MEDLINE, ClinicalTrials.gov, Embase, and Scopus were systematically searched up to 1 March 2024. This systematic review and meta-analysis was performed in line with the PRISMA and the MOOSE reporting guidelines. To thoroughly investigate the association between endometriosis/adenomyosis and adverse pregnancy outcomes, sub-analyses were conducted, whenever possible, according to: the method of conception (i.e. ART and non-ART conception), the endometriosis stage/phenotype, the coexistence of endometriosis and adenomyosis, any pre-pregnancy surgical treatment of endometriosis, and the form of adenomyosis. The odds ratio (OR) with 95% CI was used as effect measure. The quality of evidence was assessed using the GRADE approach.

OUTCOMES

We showed a higher risk of placenta previa in women with endometriosis compared to controls (34 studies, OR 2.84; 95% CI: 2.47, 3.26; I2 = 83%, moderate quality). The association was observed regardless of the method of conception and was particularly strong in the most severe forms of endometriosis (i.e. rASRM stage III-IV endometriosis and deep endometriosis (DE)) (OR 6.61; 95% CI: 2.08, 20.98; I2 = 66% and OR 14.54; 95% CI: 3.67, 57.67; I2 = 54%, respectively). We also showed an association, regardless of the method of conception, between endometriosis and: (i) preterm birth (PTB) (43 studies, OR 1.43; 95% CI: 1.32, 1.56; I2 = 89%, low quality) and (ii) cesarean section (29 studies, OR 1.52; 95% CI: 1.41, 1.63; I2 = 93%, low quality). The most severe forms of endometriosis were strongly associated with PTB. Two outcomes were associated with adenomyosis both in the main analysis and in the sub-analysis that included only ART pregnancies: (i) miscarriage (14 studies, OR 1.83; 95% CI: 1.53, 2.18; I2 = 72%, low quality) and (ii) pre-eclampsia (7 studies, OR 1.70; 95% CI: 1.16, 2.48; I2 = 77%, low quality). Regarding ART-related factors, the following associations were observed in the main analysis and confirmed in all sub-analyses conducted by pooling only risk estimates adjusted for covariates: (i) blastocyst stage embryo transfer (ET) and monozygotic twinning (28 studies, OR 2.05; 95% CI, 1.72, 2.45; I2 = 72%, low quality), (ii) frozen embryo transfer (FET) and (reduced risk of) small for gestational age (21 studies, OR 0.59; 95% CI, 0.57, 0.61; P < 0.00001; I2 = 17%, very low quality) and (increased risk of) large for gestational age (16 studies, OR 1.70; 95% CI, 1.60, 1.80; P < 0.00001; I2 = 55%, very low quality), (iii) artificial cycle (AC)-FET and pre-eclampsia (12 studies, OR 2.14; 95% CI: 1.91-2.39; I2 = 9%, low quality), PTB (21 studies, OR 1.24; 95% CI 1.15, 1.34; P < 0.0001; I2 = 50%, low quality), cesarean section (15 studies, OR 1.59; 95% CI 1.49, 1.70; P < 0.00001; I2 = 67%, very low quality) and post-partum hemorrhage (6 studies, OR 2.43; 95% CI 2.11, 2.81; P < 0.00001; I2 = 15%, very low quality).

WIDER IMPLICATIONS

Severe endometriosis (i.e. rASRM stage III-IV endometriosis, DE) constitutes a considerable risk factor for placenta previa and PTB. Herein, we recommend against superimposing on this condition other exposure factors that have a strong association with the same obstetric adverse outcome or with different outcomes which, if coexisting, could determine the onset of an ominous obstetric syndrome. Specifically, we strongly discourage the use of AC regimens for FET in ovulatory women with rASRM stage III-IV endometriosis or DE. We also recommend single ET at the blastocyst stage in this high-risk population.

REGISTRATION NUMBER

CRD42023401428.

Vanishing pelvic mass: Decidualized endometriosis during pregnancy

A 40-year-old woman without history of endometriosis was found to have 10 cm pelvic mass on the routine first trimester ultrasound. Magnetic resonance imaging (MRI) of the pelvis demonstrated a large solid mass abutting the rectum which raised the concern for malignancy. Transrectal biopsy of the mass was performed with histopathology result of decidualized endometriosis. Patient continued her pregnancy and had cesarean section at 39 weeks. Interestingly, no mass was found when obstetrician performed pelvic examination after delivery in the operative room. This case is a unique presentation of endometriosis during pregnancy in a patient with no prior history of endometriosis. Large size and abutment of the rectum by the decidualized endometriosis on MRI led to misinterpretation as malignancy. Our case highlights complexity of the deep infiltrative endometriosis (DIE) during pregnancy which can misguide the providers, lead to unnecessary procedures and unwanted complications.

Body image and depression in endometriosis: Examining self-esteem and rumination as mediators

Endometriosis is a chronic systemic disease affecting 1 in 10 people assigned female at birth, that can result in appearance-based and functional bodily changes which can negatively impact body image. Empirical evidence supports the body dissatisfaction-driven hypothesis that negative body image leads to greater depressive symptoms; but potential underlying mechanisms are under-researched. This prospective study investigated the mediating role of two theoretically-derived intervening factors, self-esteem and rumination, in individuals living with endometriosis who typically report high rates of body image concerns and depressive symptoms. Initially, 996 participants completed the first online survey (T0) assessing demographic, medical and psychological factors. Of these, 451 completed surveys at 1-month (T1) and 2-months (T2) follow-up assessing self-esteem, rumination and depression. Bootstrapped analyses with full-information maximum likelihood estimation indicated that poor body image (T0) predicted greater depressive symptoms over time (T2). Self-esteem (T1), but not rumination (T1), mediated the body image-depression relationship. These results provide support for the body dissatisfaction-driven hypothesis and further identify that self-esteem is a key meditating factor. This highlights the importance of addressing self-esteem in body image focused interventions.

Endometriosis and pregnancy: The illusion of recovery

The objective of this study was to investigate the feelings and experiences of infertile women with deep infiltrating endometriosis during and after a first pregnancy achieved by in-vitro fertilization (IVF). We conducted a qualitative monocentric study between May and November 2020. Semi-structured interviews were undertaken with infertile women with deep infiltrating endometriosis who achieved a first pregnancy by IVF and delivered at least two years prior to the interview. Data analysis was performed using an inductive approach to identify recurrent categories and themes. Fifteen interviews were conducted to reach data saturation. Pregnancy appeared to improve all components of the experience of endometriosis that were explored (psychological and physical well-being, social relationships, professional life, and sexuality). This improvement was only temporary and all symptoms and negative aspects of the women’s quality of life reappeared after a variable period.

Endometriosis and adverse pregnancy outcome

INTRODUCTION

Endometriosis is a gynecologic disease affecting approximately 10% of reproductive age women, around 21-47% of women presenting subfertility and 71-87% of women with chronic pelvic pain. Main symptoms are chronic pelvic pain, dysmenorrhea, dyspareunia and infertility that seem to be well controlled by oral contraceptive pill, progestogens, GnRh antagonists. The aim of this review was to illustrate the modern diagnosis of endometriosis during pregnancy, to evaluate the evolution of endometriotic lesions during pregnancy and the incidence of adverse outcomes.

EVIDENCE ACQUISITION

Published literature was retrieved through searches of the database PubMed (National Center for Biotechnology Information, US National Library of Medicine, Bethesda, MD, USA). We searched for all original articles published in English through April 2020 and decided to extract every notable information for potential inclusion in this review. The search included the following MeSH search terms, alone or in combination: "endometriosis" combined with "endometrioma," "biomarkers," "complications," "bowel," "urinary tract," "uterine rupture," "spontaneous hemoperitoneum in pregnancy" and more "adverse pregnancy outcome," "preterm birth," "miscarriage," "abruption placentae," "placenta previa," "hypertensive disorder," "preeclampsia," "fetal grow restriction," "small for gestation age," "cesarean delivery."

EVIDENCE SYNTHESIS

Pregnancy in women with endometriosis does not always lead to disappearance of symptoms and decrease in the size of endometriotic lesions, but it may be possible to observe a malignant transformation of ovarian endometriotic lesions. Onset of complications may be caused by many factors: chronic inflammation, adhesions, progesterone resistance and a dysregulation of genes involved in the embryo implantation. As results, the pregnancy can be more difficult because of endometriosis related complications (spontaneous hemoperitoneum [SH], bowel complications, etc.) or adverse outcomes like preterm birth, FGR, hypertensive disorders, obstetrics hemorrhages (placenta previa, abruptio placenta), miscarriage or cesarean section. Due to insufficient knowledge about its pathogenesis, currently literature data are contradictory and do not show a strong correlation between endometriosis and these complications except for miscarriage and cesarean delivery.

CONCLUSIONS

Future research should focus on the potential biological pathways underlying these relationships in order to inform patients planning a birth about possible complications during pregnancy.

Decidualization of endometriosis in a cohort of IVF-mediated pregnancies

Decidualization is the process of endometrial change in pregnancy, a phenomenon that can involve also ovarian endometriomas. However, the frequency of this event remains unknown. In addition, there is no evidence on the decidualization of deep invasive endometriosis (DIE). To shed more light on this issue, we prospectively recruited women with ovarian endometriomas or DIE who underwent IVF. They were subsequently excluded if they did not become pregnant or if they had a miscarriage. The evaluation was repeated in five time points during pregnancy and post-partum. The primary outcome was the rate of decidualized endometriomas at 11-13 weeks' gestation. Data from 45 endometriomas and 15 nodules were available for data analyses. At the 11-13 weeks' ultrasound, endometriomas' decidualization was observed in seven cases, corresponding to 16% (95% CI 8-29%). Subsequent assessments in pregnancy failed to identify any additional case. DIE also underwent significant changes during pregnancy. At the 11-13 weeks' ultrasound, lesions were increased in size and more vascularized. In conclusion, decidualization of ovarian endometriomas in IVF pregnancies is not rare. DIE may also undergo decidualization, but further evidence is needed for a robust and shared definition of this process.

Adnexal Masses in Pregnancy

Importance

Adnexal masses are identified in approximately 0.05% to 2.4% of pregnancies, and more recent data note a higher incidence due to widespread use of antenatal ultrasound. Whereas most adnexal masses are benign, approximately 1% to 6% are malignant. Proper diagnosis and management of adnexal masses in pregnancy are an important skill for obstetricians.

Objective

The aim of this study was to review imaging modalities for evaluating adnexal masses in pregnancy and imaging characteristics that differentiate benign and malignant masses, examine various types of adnexal masses, and understand complications of and explore management options for adnexal masses in pregnancy.

Evidence Acquisition

This was a literature review using primarily PubMed and Google Scholar.

Results

Ultrasound can distinguish between simple-appearing benign ovarian cysts and masses with more complex features that can be associated with malignancy. Radiologic information can help guide physicians toward recommending conservative management with observation or surgical removal during pregnancy to facilitate diagnosis and treatment. The risks of expectant management of an adnexal mass during pregnancy include rupture, torsion, need for emergent surgery, labor obstruction, and progression of malignancy. Historically, surgical removal was performed more routinely to avoid such complications in pregnancy; however, increasing knowledge has directed management toward conservative measures for benign masses. Surgical removal of adnexal masses is increasingly performed via minimally invasive techniques including laparoscopy and robotic surgery due to a decreased risk of surgical complications compared with laparotomy.

Conclusions and Relevance

Adnexal masses are increasingly identified in pregnancy because of the use of antenatal ultrasound. Clear and specific guidelines exist to help differentiate between benign and malignant masses. This is important for management as benign masses can usually be conservatively managed, whereas malignant masses require excision for diagnosis and treatment. A multidisciplinary approach, including referral to gynecologic oncology, should be used for masses with complex features associated with malignancy. Proper diagnosis and management of adnexal masses in pregnancy are an important skill for obstetricians.

Characteristics of ovarian endometrioma during pregnancy

AIM

During pregnancy, the ovarian endometrioma generally decreases in size and occasionally ruptures. We evaluated (1) whether and how ovarian-endometrioma size changes from the first trimester to the postdelivery period, and (2) the type of endometrioma more likely to rupture during pregnancy.

METHODS

During an 18-year period (2000-2018), ultrasound in the first trimester revealed ovarian endometrioma in 149 pregnant women at our tertiary institute. Among these, we subjected 138 endometriomas in 145 patients to expectant management (wait-and-watch approach during pregnancy). We compared the cyst sizes in the first trimester and the postdelivery period, and defined a >1 cm diameter size-change as a significant increase/decrease. We analyzed four patients with rupture and characterized the predictors of rupture.

RESULTS

A comparison of cyst sizes in the first trimester and the postdelivery period revealed that the size of 94 (68%), 37 (27%), and 7 ovaries (5.0%), respectively, decreased, remained unchanged, and increased; in 56 ovaries (40%), apparent cysts were no longer present. Of the 145 patients, four (2.8%) required emergency surgery for cyst rupture. Adhesion to the surroundings, an increase in cyst size, large size (diameter of ≥6 cm), and compression due to the enlarged uterus in late pregnancy were factors clinically related to rupture.

CONCLUSIONS

Approximately two-thirds of ovarian endometriomas decreased in size during pregnancy (40% disappeared), 27% remained unchanged, and only 5% increased in size. However, 2.8% of pregnant women with endometrial cysts experienced rupture. We characterized risk factors for rupture; however, clinical application requires further evaluation.

Management of endometriosis-related infertility: Considerations and treatment options

Endometriosis is a common inflammatory disease in women of reproductive age and is one of the major causes of infertility. Endometriosis causes a sustained reduction of ovarian reserve through both physical mechanisms and inflammatory reactions, which result in the production of reactive oxygen species and tissue fibrosis. The severity of endometriosis is related to ovarian reserve. With regard to infertility treatment, medical therapy as a neoadjuvant or adjuvant to surgical therapy has no definite beneficial effect. Surgical treatment of endometriosis can lead to ovarian injury during the resection of endometriotic tissue, which leads to the deterioration of ovarian reserve. To overcome this disadvantage, a multistep technique has been proposed to minimize the reduction of ovarian reserve. When considering surgical treatment of endometriosis in patients experiencing infertility, it should be kept in mind that ovarian reserve can be reduced both due to endometriosis itself and by the process of removing endometriosis. In cases of mild- to moderate-stage endometriosis, intrauterine insemination with ovarian stimulation after surgical treatment may increase the likelihood of pregnancy. In cases of severe endometriosis, the characteristics of the patient should be considered in a multidisciplinary manner to determine the prioritization of treatment modalities, including surgical treatment and assisted reproduction methods such as in vitro fertilization. The risk of cancer, complications after pregnancy, and infection during oocyte retrieval should also be considered when making treatment decisions.

Magnetic resonance imaging presentation of deep infiltrating endometriosis nodules before and after pregnancy: A case series

OBJECTIVE

To compare the magnetic resonance imaging (MRI) features of deep infiltrating endometriosis (DIE) lesions before and after pregnancy.

DESIGN

Retrospective study.

SETTING

A single French university tertiary referral hospital.

PATIENTS

Twenty-one women without a prior history of surgery for endometriosis with a radiological diagnosis by MRI with two sets of examinations performed before and after pregnancy.

INTERVENTIONS

The volumes of the lesions were compared using the same protocol before and after pregnancy based on MRI (1.5 T) examinations by a single experienced radiologist who is a referring practitioner for image-based diagnosis of endometriosis.

MAIN OUTCOME MEASURE(S)

The DIE lesion volume.

MEASUREMENTS AND MAIN RESULTS

Between October 2012 and December 2016, a total of 21 patients (67 lesions) were included and compared before and after pregnancy. The mean time interval between the MRI before pregnancy and delivery was 19.6 ± 8.5 months (median: 17.6, IQR 13.5-25.2 months). The mean time interval between delivery and the MRI after pregnancy was 11.0 ± 6.4 months (median: 8.3, IQR 6-15.2 months). The mean overall DIE lesion volume by MRI was significantly higher before pregnancy compared to after pregnancy (2,552 ± 3,315 mm3 vs. 1,708 ± 3,266 mm3, respectively, p < 0.01). The mean volume by MRI of the largest lesion of each patient was significantly higher before pregnancy compared to after pregnancy (4,728 ± 4,776 mm3 vs. 3165 ± 5299 mm3; p < 0.01).

CONCLUSION

Our data indicate a favorable impact of pregnancy on DIE lesion volumes as measured by MRI.

Human Chorionic Gonadotrophin as a Possible Mediator of Leiomyoma Growth during Pregnancy: Molecular Mechanisms

Uterine fibroids are the most common gynecologic benign tumors. Studies supporting a strong pregnancy-related growth of leiomyomas generally claimed a crucial role of sex steroid hormones. However, sex steroids are unlikely the unique actors involved as estrogen and progesterone achieve a pick serum concentration in the last trimester while leiomyomas show a typical increase during the first trimester. Given the rapid exponential raise in serum human Chorionic Gonadotrophin (hCG) at the beginning of gestation, we conducted a review to assess the potential role of hCG in the striking growth of leiomyomas during initial pregnancy. Fibroid growth during initial pregnancy seems to correlate to the similar increase of serum hCG levels until 12 weeks of gestation. The presence of functional Luteinizing Hormone/human Chorionic Gonadotropin (LH/hCG) receptors was demonstrated on leiomyomas. In vitro treatment of leiomyoma cells with hCG determines an up to 500% increase in cell number after three days. Expression of cyclin E and cyclin-dependent kinase 1 was significantly increased in leiomyoma cells by hCG treatment. Moreover, upon binding to the receptor, hCG stimulates prolactin secretion in leiomyoma cells, promoting cell proliferation via the mitogen-activated protein kinase cascade. Fibroid enlargement during initial pregnancy may be regulated by serum hCG.

A systematic review on endometriosis during pregnancy: diagnosis, misdiagnosis, complications and outcomes

BACKGROUND

Traditionally, pregnancy was considered to have a positive effect on endometriosis and its painful symptoms due not only to blockage of ovulation preventing bleeding of endometriotic tissue but also to different metabolic, hormonal, immune and angiogenesis changes related to pregnancy. However, a growing literature is emerging on the role of endometriosis in affecting the development of pregnancy and its outcomes and also on the impact of pregnancy on endometriosis. The present article aims to underline the difficulty in diagnosing endometriotic lesions during pregnancy and discuss the options for the treatment of decidualized endometriosis in relation to imaging and symptomatology; to describe all the possible acute complications of pregnancy caused by pre-existing endometriosis and evaluate potential treatments of these complications; to assess whether endometriosis affects pregnancy outcome and hypothesize mechanisms to explain the underlying relationships.

METHODS

This systematic review is based on material searched and obtained via Pubmed and Medline between January 1950 and March 2015. Peer-reviewed, English-language journal articles examining the impact of endometriosis on pregnancy and vice versa were included in this article.

RESULTS

Changes of the endometriotic lesions may occur during pregnancy caused by the modifications of the hormonal milieu, posing a clinical dilemma due to their atypical appearance. The management of these events is actually challenging as only few cases have been described and the review of available literature evidenced a lack of formal estimates of their incidence. Acute complications of endometriosis during pregnancy, such as spontaneous hemoperitoneum, bowel and ovarian complications, represent rare but life-threatening conditions that require, in most of the cases, surgical operations to be managed. Due to the unpredictability of these complications, no specific recommendation for additional interventions to the routinely monitoring of pregnancy of women with known history of endometriosis is advisable. Even if the results of the published studies are controversial, some evidence is suggestive of an association of endometriosis with spontaneous miscarriage, preterm birth and small for gestational age babies. A correlation of endometriosis with placenta previa (odds ratio from 1.67 to 15.1 according to various studies) has been demonstrated, possibly linked to the abnormal frequency and amplitude of uterine contractions observed in women affected. Finally, there is no evidence that prophylactic surgery would prevent the negative impact of endometriosis itself on pregnancy outcome.

CONCLUSIONS

Complications of endometriosis during pregnancy are rare and there is no evidence that the disease has a major detrimental effect on pregnancy outcome. Therefore, pregnant women with endometriosis can be reassured on the course of their pregnancies although the physicians should be aware of the potential increased risk of placenta previa. Current evidence does not support any modification of conventional monitoring of pregnancy in patients with endometriosis.