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Gasimli K, Akpinar D, Gasimli B, Bachmann A, Maczó N, De Wilde RL, Naem A, Krentel H, Becker S, Tahmasbi Rad M. Postoperative Reproductive Outcomes in Patients with Endometriosis-Associated Infertility: A Single-Center Retrospective Study. Gynecol Obstet Invest 2024:1-8. [PMID: 38705138 DOI: 10.1159/000539142] [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: 02/22/2024] [Accepted: 04/21/2024] [Indexed: 05/07/2024]
Abstract
OBJECTIVES Endometriosis is a chronic inflammatory disease known to contribute to infertility. Laparoscopic excision of endometriotic lesions represents a standard treatment modality for symptomatic women. Our study aims to assess the potential benefits of laparoscopic excision of endometriosis in patients experiencing infertility associated with the condition, as well as to define the clinical factors that may impact the cumulative pregnancy rate. DESIGN In this retrospective analysis, a total of 102 patients with endometriosis-related infertility were enrolled. MATERIALS, SETTING, METHODS All participants underwent reproductive surgery and were then categorized into two groups: those who conceived were assigned to group A, while those who did not were assigned to group B. The correlation between clinical factors and pregnancy rate was assessed using the log-rank test, and both univariate and multivariate analyses were conducted utilizing the Cox regression model. RESULTS The median age of the patients was 33.5 years, with a median follow-up duration of 70 months. Throughout the study period, 71 patients (69.6%) conceived (group A), while the remaining 31 patients (30.4%) did not conceive (group B), irrespective of the use of Assisted-Reproduction Technologies. The Cox regression model revealed that factors such as the duration of infertility, presence of deep infiltrating endometriosis, bowel endometriosis, rASRM stages, pelvic adhesions, and recurrent disease negatively impacted postoperative conception rates. Conversely, complete excision and coagulation of endometriotic lesions, as well as ablation of ovarian endometriomas, emerged as independent positive predictive factors for postoperative clinical pregnancy. LIMITATIONS Limitations of this study is retrospective design of the study, as well as a small number of patients. CONCLUSIONS Complete excision of endometriosis during reproductive surgery may yield a positive effect and optimize the likelihood of pregnancy in patients with endometriosis-related infertility.
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Affiliation(s)
- Khayal Gasimli
- Department of Gynecology and Obstetrics, J.W. Goethe-University Frankfurt, Frankfurt, Germany
| | - Dilara Akpinar
- Department of Gynecology and Obstetrics, J.W. Goethe-University Frankfurt, Frankfurt, Germany
- Department of Hepatology and Gastroenterology, Schwarzwald-Baar Klinikum, Villingen-Schwenningen, Germany
| | - Bahar Gasimli
- Department of Gynecology and Obstetrics, J.W. Goethe-University Frankfurt, Frankfurt, Germany
| | - Annette Bachmann
- Department of Gynecology and Obstetrics, J.W. Goethe-University Frankfurt, Frankfurt, Germany
| | - Norbert Maczó
- Department of Gynecology and Obstetrics, J.W. Goethe-University Frankfurt, Frankfurt, Germany
| | - Rudy Leon De Wilde
- Department of Gynecology, Carl-von-Ossietzky University, Oldenburg, Germany
| | - Antoine Naem
- Department of Obstetrics, Gynecology, Gynecologic Oncology and Senology, Bethesda Hospital Duisburg, Duisburg, Germany
- Faculty of Mathematics and Computer Science, University of Bremen, Bremen, Germany
| | - Harald Krentel
- Department of Obstetrics, Gynecology, Gynecologic Oncology and Senology, Bethesda Hospital Duisburg, Duisburg, Germany
| | - Sven Becker
- Department of Gynecology and Obstetrics, J.W. Goethe-University Frankfurt, Frankfurt, Germany
| | - Morva Tahmasbi Rad
- Department of Gynecology and Obstetrics, J.W. Goethe-University Frankfurt, Frankfurt, Germany
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Ferrari FA, Youssef Y, Naem A, Ferrari F, Odicino F, Krentel H, Moawad G. Robotic surgery for deep-infiltrating endometriosis: is it time to take a step forward? Front Med (Lausanne) 2024; 11:1387036. [PMID: 38504917 PMCID: PMC10948538 DOI: 10.3389/fmed.2024.1387036] [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: 02/16/2024] [Accepted: 02/26/2024] [Indexed: 03/21/2024] Open
Abstract
Endometriosis is a chronic debilitating disease that affects nearly 10% of women of the reproductive age. Although the treatment modalities of endometriosis are numerous, surgical excision of the endometriotic implants and nodules remains the sole cytoreductive approach. Laparoscopic excision of endometriosis was proven to be beneficial in improving the postoperative pain and fertility. Moreover, it was also proved to be safe and efficient in treating the visceral localization of deep endometriosis, such as urinary and colorectal endometriosis. More recently, robotic-assisted surgery gained attention in the field of endometriosis surgery. Although the robotic technology provides a 3D vision of the surgical field and 7-degree of freedom motion, the safety, efficacy, and cost-effectiveness of this approach are yet to be determined. With this paper, we aim to review the available evidence regarding the role of robotic surgery in the management of endometriosis along with the current practices in the field.
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Affiliation(s)
| | - Youssef Youssef
- Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynaecology-Maimonides Medical Center, Brooklyn, NY, United States
| | - Antoine Naem
- Faculty of Mathematics and Computer Science, University of Bremen, Bremen, Germany
- Department of Obstetrics, Gynecology, Gynecologic Oncology, and Senology, Bethesda Hospital Duisburg, Duisburg, Germany
| | - Federico Ferrari
- Department of Clinical and Experimental Sciences, Division of Obstetrics and Gynecology, University of Brescia, Brescia, Italy
| | - Franco Odicino
- Department of Clinical and Experimental Sciences, Division of Obstetrics and Gynecology, University of Brescia, Brescia, Italy
| | - Harald Krentel
- Department of Obstetrics, Gynecology, Gynecologic Oncology, and Senology, Bethesda Hospital Duisburg, Duisburg, Germany
| | - Gaby Moawad
- Department of Obstetrics and Gynecology, George Washington University, Washington, DC, United States
- The Center for Endometriosis and Advanced Pelvic Surgery, Washington, DC, United States
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Ferrari F, Epis M, Casarin J, Bordi G, Gisone EB, Cattelan C, Rossetti DO, Ciravolo G, Gozzini E, Conforti J, Cromi A, Laganà AS, Ghezzi F, Odicino F. Long-term therapy with dienogest or other oral cyclic estrogen-progestogen can reduce the need for ovarian endometrioma surgery. WOMEN'S HEALTH (LONDON, ENGLAND) 2024; 20:17455057241252573. [PMID: 38738634 PMCID: PMC11092536 DOI: 10.1177/17455057241252573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 04/10/2024] [Accepted: 04/17/2024] [Indexed: 05/14/2024]
Abstract
BACKGROUND Almost 10% of women in reproductive age are diagnosed with ovarian endometriomas and can experience symptoms and infertility disorders. Ovarian endometriomas can be treated with medical or surgical therapy. OBJECTIVE To assess whether long-term therapy with dienogest or oral cyclic estrogen-progestogens is effective in reducing the size of ovarian endometriomas, alleviating associated symptoms, and reducing the requirement for surgery. DESIGN Prospective non-interventional cohort study. METHODS We enrolled childbearing women diagnosed with ovarian endometriomas. We collected demographic, clinical, and surgical data, including the evaluation of ovarian endometrioma-associated symptoms and pain using the visual analog scale. We grouped the women according to treatment regimen into dienogest, estrogen-progestogens, and no-treatment. Patient's assessment was performed at baseline and after 12 months evaluating the largest ovarian endometrioma diameter (in millimeters) and the associated symptoms. Furthermore, we analyzed the impact of hormonal treatment in a sub-group of women fulfilling at baseline the criteria for a first-line surgical approach (ovarian endometrioma > 30 mm with visual analog scale > 8 or ovarian endometrioma > 40 mm before assisted reproductive treatments or any ovarian endometrioma(s) > 60 mm). RESULTS We enrolled 142 patients: 62, 38, and 42 in dienogest, estrogen-progestogens, and no-treatment groups, respectively. No significant differences were found regarding baseline characteristics. After 12 months, the mean largest ovarian endometrioma diameter increased in the no-treatment group (31.1 versus 33.8; p < 0.01), while a significant reduction was registered in the dienogest (35.1 versus 25.8; p < 0.01) and estrogen-progestogens (28.4 versus 16.7; p < 0.01) groups; no significant difference in ovarian endometrioma diameter reduction between these two latter groups was noted (p = 0.18). Ovarian endometrioma-associated symptoms and pain improved in dienogest and estrogen-progestogens groups, with a significantly greater effect for dienogest than for estrogen-progestogens for dysmenorrhea (74% versus 59%; p < 0.01). In the sub-group of women eligible for first-line surgery at baseline, long-term treatment with dienogest and estrogen-progestogens reduced surgical eligibility by 30%. CONCLUSIONS Decreased mean largest ovarian endometriomas'diameter after 12 months and reduction of the need for surgical treatment by 30% were observed in dienogest and estrogen-progestogens groups. Long-term treatment with dienogest had a greater effect in alleviating dysmenorrhea and pain.
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Affiliation(s)
- Federico Ferrari
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
- S.C. Ginecologia e Ostetricia, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Matteo Epis
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Jvan Casarin
- Department of Obstetrics and Gynecology, “Filippo Del Ponte” Hospital, University of Insubria, Varese, Italy
| | - Giulia Bordi
- Department of Obstetrics and Gynecology, “Filippo Del Ponte” Hospital, University of Insubria, Varese, Italy
| | - Emanuele Baldo Gisone
- Department of Obstetrics and Gynecology, “Filippo Del Ponte” Hospital, University of Insubria, Varese, Italy
| | - Chiara Cattelan
- Department of Obstetrics and Gynecology, “Filippo Del Ponte” Hospital, University of Insubria, Varese, Italy
| | | | - Giuseppe Ciravolo
- S.C. Ginecologia e Ostetricia, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Elisa Gozzini
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
- S.C. Ginecologia e Ostetricia, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Jacopo Conforti
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
- S.C. Ginecologia e Ostetricia, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Antonella Cromi
- Department of Obstetrics and Gynecology, “Filippo Del Ponte” Hospital, University of Insubria, Varese, Italy
| | - Antonio Simone Laganà
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
- Unit of Obstetrics and Gynecology, “Paolo Giaccone” Hospital, Palermo, Italy
| | - Fabio Ghezzi
- Department of Obstetrics and Gynecology, “Filippo Del Ponte” Hospital, University of Insubria, Varese, Italy
| | - Franco Odicino
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
- S.C. Ginecologia e Ostetricia, ASST Spedali Civili di Brescia, Brescia, Italy
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Vitale SG, Angioni S, Parry JP, Di Spiezio Sardo A, Haimovich S, Carugno J, Alonso Pacheco L, Perez-Medina T, Moawad N, De Franciscis P, Riemma G. Efficacy of Hysteroscopy in Improving Fertility Outcomes in Women Undergoing Assisted Reproductive Technique: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Gynecol Obstet Invest 2023; 88:336-348. [PMID: 37899034 PMCID: PMC10794974 DOI: 10.1159/000534794] [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: 08/26/2023] [Accepted: 10/15/2023] [Indexed: 10/31/2023]
Abstract
INTRODUCTION Usefulness of hysteroscopy before assisted reproductive technique (ART) was considered debatable. However, over the last decade, several new trials have been added to available literature. We aimed to assess the impact of diagnostic and operative hysteroscopy on reproductive outcomes of infertile women with and without intrauterine abnormalities. MATERIALS AND METHODS MEDLINE, Scopus, SciELO, Embase, Cochrane Library at CENTRAL, PROSPERO, CINAHL, grey literature, conference proceedings, and international controlled trials registries were searched without temporal, geographical, or language restrictions. Randomized controlled trials (RCTs) of infertile women comparing hysteroscopy versus no hysteroscopy prior to the first ART or after at least one failed attempt were included. RCTs of infertile women with intrauterine pathology comparing diagnostic versus operative hysteroscopy were included in separate analysis. Random-effect meta-analysis was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Grading of Recommendations, Assessment, Development and Evaluation and Cochrane criteria were used for quality of evidence and risk of bias assessment. Primary outcome was live birth rate (LBR). Secondary outcomes were clinical pregnancy (CPR) and pregnancy loss rate. RESULTS Fifteen studies (5,038 women) were included. Compared to no hysteroscopy before first or after failed ART attempts, moderate-quality evidence showed that hysteroscopy increased the LBR (relative risk [RR] 1.24, 95% confidence interval [CI] 1.09-1.43, I2 = 21%), confirmed by subgroup analysis for women with failure after one or more ART cycles (RR 1.43, 95% CI: 1.19-1.72, I2 = 0%) but not before the first ART. Moderate-quality evidence showed that it increased the CPR (RR 1.36, 95% CI: 1.18-1.57; I2 = 51%), confirmed in subgroup analysis for both implantation failure (RR 1.40, 95% CI: 1.12-1.74, I2 = 52%) and before first ART (RR 1.32, 95% CI: 1.11-1.57, I2 = 42%). Low-quality data suggest that operative hysteroscopy increases CPR when used to treat intrauterine pathologies (RR 2.13, 95% CI: 1.56-2.92, I2 = 0%). CONCLUSIONS Although moderate-quality evidence supports performing hysteroscopy before ART in women with history of implantation failure, hysteroscopic evaluation of uterine cavity should be considered a first-line technique in all infertile women undergoing ART. Additional high-quality RCTs are still needed, particularly to assess yield during couple's initial evaluation even before ART is considered.
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Affiliation(s)
- Salvatore Giovanni Vitale
- Division of Gynecology and Obstetrics, Department of Surgical Sciences, University of Cagliari, Cagliari, Italy
| | - Stefano Angioni
- Division of Gynecology and Obstetrics, Department of Surgical Sciences, University of Cagliari, Cagliari, Italy
| | - John Preston Parry
- Parryscope and Positive Steps Fertility, Madison, MS, USA
- Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Attilio Di Spiezio Sardo
- Department of Public Health, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Sergio Haimovich
- Department of Obstetrics and Gynecology, Laniado University Hospital, Netanya, Israel
- Adelson School of Medicine, Ariel University, Ariel, Israel
| | - Jose Carugno
- Obstetrics, Gynecology, and Reproductive Science Department, Minimally Invasive Gynecology Division, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Luis Alonso Pacheco
- Unidad De Endoscopia Ginecológica, Centro Gutenberg, Hospital Xanit Internacional, Málaga, Spain
| | - Tirso Perez-Medina
- Department of Obstetrics and Gynecology, University Hospital Puerta De Hierro Majadahonda, Autonoma University of Madrid, Madrid, Spain
| | - Nash Moawad
- Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Pasquale De Franciscis
- Department of Woman, Child and General and Specialized Surgery, Obstetrics and Gynecology Unit, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Gaetano Riemma
- Department of Woman, Child and General and Specialized Surgery, Obstetrics and Gynecology Unit, University of Campania “Luigi Vanvitelli”, Naples, Italy
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Naem A, Andrikos A, Constantin AS, Khamou M, Andrikos D, Laganà AS, De Wilde RL, Krentel H. Diaphragmatic Endometriosis-A Single-Center Retrospective Analysis of the Patients' Demographics, Symptomatology, and Long-Term Treatment Outcomes. J Clin Med 2023; 12:6455. [PMID: 37892593 PMCID: PMC10607902 DOI: 10.3390/jcm12206455] [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: 09/21/2023] [Revised: 10/06/2023] [Accepted: 10/09/2023] [Indexed: 10/29/2023] Open
Abstract
Diaphragmatic endometriosis is rare and forms 0.67-4.7% of all endometriosis cases. Evidence regarding its optimal management is lacking. In this study, we retrospectively analyzed the patient characteristics and long-term treatment outcomes of diaphragmatic endometriosis patients. Over a 4-year period, 23 patients were diagnosed with diaphragmatic endometriosis. The majority of patients had coexisting deep pelvic endometriosis. Cyclic upper abdominal pain was reported by 60.9% of patients, while cyclic chest and shoulder pain were reported by 43.5% and 34.8% of patients, respectively. Most patients were treated with laparoscopic lesion ablation, while 21.1% were treated with minimally invasive excision. The mean follow-up time was 23.7 months. Long-lasting resolution of the chest, abdominal, and shoulder pain occurred in 50%, 35.7%, and 25% of patients, respectively. Nonetheless, 78.9% of patients reported major improvement in their symptoms postoperatively. Significantly higher rates of postoperative shoulder, abdominal, and chest pain were observed in patients who received postoperative hormonal therapy compared with those who did not. All patients treated expectantly remained stable. Therefore, we recommend treating diaphragmatic endometriosis only in symptomatic patients. The risk of incomplete surgery should be minimized by a multidisciplinary diagnostic and therapeutic approach with a careful assessment of the diaphragm and the thoracic cavity.
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Affiliation(s)
- Antoine Naem
- Department of Obstetrics, Gynecology, Gynecologic Oncology and Senology, Bethesda Hospital Duisburg, 47053 Duisburg, Germany; (A.A.); (D.A.); (H.K.)
- Faculty of Mathematics and Computer Science, University of Bremen, 28359 Bremen, Germany
| | - Argyrios Andrikos
- Department of Obstetrics, Gynecology, Gynecologic Oncology and Senology, Bethesda Hospital Duisburg, 47053 Duisburg, Germany; (A.A.); (D.A.); (H.K.)
| | | | - Michael Khamou
- Department of Radiology, Bethesda Hospital Duisburg, 47053 Duisburg, Germany
| | - Dimitrios Andrikos
- Department of Obstetrics, Gynecology, Gynecologic Oncology and Senology, Bethesda Hospital Duisburg, 47053 Duisburg, Germany; (A.A.); (D.A.); (H.K.)
| | - Antonio Simone Laganà
- Unit of Obstetrics and Gynecology, “Paolo Giaccone” Hospital, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90127 Palermo, Italy;
| | - Rudy Leon De Wilde
- Clinic of Gynecology, Obstetrics and Gynecological Oncology, University Hospital for Gynecology, Pius-Hospital Oldenburg, Medical Campus University of Oldenburg, 26121 Oldenburg, Germany
| | - Harald Krentel
- Department of Obstetrics, Gynecology, Gynecologic Oncology and Senology, Bethesda Hospital Duisburg, 47053 Duisburg, Germany; (A.A.); (D.A.); (H.K.)
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