Deep Endometriosis and Infertility: What Is the Impact of Surgery?

The (cost-) effectiveness Of Surgical excision of Colorectal endometriosis compared to ART treatment trAjectory (TOSCA study) - a study protocol

Currently, the optimal treatment to increase the chance of pregnancy and live birth in patients with colorectal endometriosis and subfertility is unknown. Evidence suggests that that both surgery and in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) are effective in improving live birth rate (LBR) among these women. However, the available evidence is of low quality, reports highly heterogeneous results, lacks direct comparison between both treatment options and does not assess whether a combination strategy results in a higher LBR compared to IVF/ICSI-only treatment. Additionally, the optimal timing of surgery within the treatment trajectory remains unclear. The primary objective of the TOSCA study is to assess the effectiveness of surgical treatment (potentially combined with IVF/ICSI) compared to IVF/ICSI-only treatment to increase the chance of an ongoing pregnancy resulting in a live birth in patients with colorectal endometriosis and subfertility, measured by cumulative LBR. Secondary objectives are to assess and compare quality of life and cost-effectiveness in both groups. Patients will be followed for 40 months after inclusion or until live birth. The TOSCA study is expected to be completed in 6 years.

Surgical treatment of deep endometriosis: Impact on spontaneous conception

Deep endometriosis (DE) is the most severe form of endometriosis and is commonly associated with infertility. Surgical treatment of DE appears to increase chances of spontaneous conception in appropriately selected patients wishing to conceive. Identifying, however, the exact impact of DE, and its surgical removal, on natural conception is highly challenging. The surgical approach should be favoured in symptomatic patients with pregnancy intention. Limited data from infertile patients suggest that outcomes may not differ from patients without known infertility. Complex DE surgery carries a risk of serious complications, therefore, it should be performed in centers of expertise. Such complications may, however, not have a significant negative impact on fertility outcomes, according to limited available data. Data on obstetric outcomes of spontaneous conceptions after DE surgery are too scarce. In asymptomatic, infertile patients the debate between primary surgery or Artifial Reproductive Technology is ongoing, until randomized studies report their results.

The impact of endometriosis on depressive and anxiety symptoms and quality of life: a systematic review

Introduction

Endometriosis is a common gynecological disorder affecting approximately 10-15% of women of reproductive age. The main complaints of patients with endometriosis are pain and fertility problems. Symptoms of endometriosis can impact the psychological functioning of the patients and significantly compromise their mental health.

Methods

The aim of this review was to assess the prevalence of depressive and anxiety symptoms and quality of life in endometriosis patients. For this systematic review, we searched the PubMed, MEDLINE, ProQuest, EMBASE, Cochrane, CINAHL, Google Scholar, Scopus, and ScienceDirect electronic databases up to March 2023 to identify potentially relevant studies. The systematic review in the present paper is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidance.

Results

Of four records identified, 18 were eligible to be reviewed on the association between endometriosis and symptoms of depression and anxiety. Of 8,901 records identified, 28 were reviewed on the association between endometriosis and quality of life. The reviewed articles showed a prevalence ranging from 9.8 to 98.5% for depressive symptoms and 11.5 to 87.5% for anxiety. The quality of life in patients with endometriosis was significantly impaired, regardless of the tool used for evaluation.

Discussion

This systematic review shows that endometriosis is associated with depressive and anxiety symptoms and impaired HRQoL. Broad correlating factors modulate mental health outcomes, indicating the complex relationship between the disease and the psychological health of the patients.

Spatiotemporal Trends and Age-Period-Cohort Analysis for the Burden of Endometriosis-Related Infertility: An Analysis of the Global Burden of Disease Study 2019

BACKGROUND

Endometriosis is a common nonfatal gynecological disease, and infertility is one of its main dangers. Endometriosis-related infertility causes serious damage to women's health and places a burden on women of reproductive age. The aim of this study was to describe the current burden of endometriosis-associated infertility and to analyze its spatiotemporal trends.

METHODS

Age-standardized prevalence rate (ASPR) data from 1990 to 2019 for Endometriosis-related primary infertility (ERPI) and secondary infertility (ERSI) were obtained from the Global Burden of Disease Study (GBD) 2019. These data spanning three decades cover the global, sociodemographic index (SDI) regions, GBD regions, and 204 countries and territories. Spatiotemporal trends were analyzed by calculating the estimated annual percentage change (EAPC) and using a time-period-cohort model.

RESULTS

Globally, the ASPR of ERPI and ERSI showed a weak downward trend from 1990 to 2019, with EAPCs of -1.25 (95% CI: -1.39 to -1.11) and -0.6 (95% CI: -0.67 to -0.53), respectively. The spatiotemporal trends in ERPI and ERSI varied substantially between regions and age groups. When endometriosis-related infertility burden was linked to SDI values, a strong negative correlation was observed between the ASPR of ERSI and its EAPC and SDI values. When modeling with age-period-cohort, ERPI burden was found to be highest at ages 20-25 years, while ERSI burden was persistently higher at ages 20-45 years. Using 2000-2004 as the reference period, both ERPI and ERSI burden decreased with each year among women. Significant variability in burden between regions was found for the birth cohort factor.

CONCLUSIONS

The global burden of endometriosis-related infertility declined minimally from 1990 to 2019. However, this burden varied considerably across regions, age groups, periods, and birth cohorts. The results of this study reflect spatiotemporal trends in the burden of endometriosis-related infertility over the study period and may be used to help improve health management, develop timely and effective prevention and control strategies, and provide epidemiologic theoretical evidence for reducing the burden for endometriosis-related infertility.

Predictive Model for the Non-Invasive Diagnosis of Endometriosis Based on Clinical Parameters

OBJECTIVES

Are other pain symptoms in addition to dysmenorrhea, dyspareunia, dyschezia, dysuria, and chronic pelvic pain correlated to endometriosis and suitable for a clinical prediction model?

METHODS

We conducted a prospective study from 2016 to 2022, including a total of 269 women with numerous pain symptoms and other parameters. All women filled out two questionnaires and were examined by palpation and transvaginal ultrasound (TVUS). In cases of suspected deep endometriosis, magnetic resonance imaging (MRI) was performed. After the operation, endometriosis was diagnosed by histological examination.

RESULTS

All in all, 30 significant parameters and 6 significant numeric rating scale (NRS) scores associated with endometriosis could be identified: 7 pain adjectives, 8 endometriosis-associated pain symptoms, 5 pain localizations, 6 parameters from the PainDETECT, consumption of analgesics, and allergies. Furthermore, longer pain duration (before, during, and after menstruation) was observed in women with endometriosis compared to women without endometriosis (34.0% vs. 12.3%, respectively). Although no specific pain for endometriosis could be identified for all women, a subgroup with endometriosis reported radiating pain to the thighs/legs in contrast to a lower number of women without endometriosis (33.9% vs. 15.2%, respectively). Furthermore, a subgroup of women with endometriosis suffered from dysuria compared to patients without endometriosis (32.2% vs. 4.3%, respectively). Remarkably, the numbers of significant parameters were significantly higher in women with endometriosis compared to women without endometriosis (14.10 ± 4.2 vs. 7.75 ± 5.8, respectively). A decision tree was developed, resulting in 0.904 sensitivity, 0.750 specificity, 0.874 positive predictive values (PPV), 0.802 negative predictive values (NPV), 28.235 odds ratio (OR), and 4.423 relative risks (RR). The PPV of 0.874 is comparable to the positive prediction of endometriosis by the clinicians of 0.86 (177/205).

CONCLUSIONS

The presented predictive model will enable a non-invasive diagnosis of endometriosis and can also be used by both patients and clinicians for surveillance of the disease before and after surgery. In cases of positivety, as evaluated by the questionnaire, patients can then seek advice again. Similarly, patients without an operation but with medical therapy can be monitored with the questionnaire.

The Utility of Rectal Water Contrast Transvaginal Ultrasound for Assessment of Deep Bowel Endometriosis

Deep infiltrating endometriosis (DIE) is characterized by the presence of endometrial tissue outside the uterine cavity that infiltrates at least 5-mm deep below the peritoneal layer. Imagining examinations are the first-choice methods to detect DIE. The aim of this study is to assess whether rectal water contrast transvaginal sonography (RWC-TVS) can be a useful tool for the estimation of the size of deep bowel endometriotic nodules. This retrospective study includes 31 patients subjected to RWC-TVS who underwent surgery due to deep bowel endometriosis between January 2021 and December 2022. Nodule dimensions measured via ultrasound were compared to those of histopathological samples taken after surgery. In total, 52% of patients had endometriosis limited only to the intestines, 19% had endometriotic nodules located at uterosacral ligaments and posterior vaginal fornix, 6% at the anterior compartment, and 13% at a different location. Additionally, 6% of patients had nodules at more than two locations. In all but one case, the intestinal nodules could be seen on RWC-TVS images. The largest nodule dimension measured via RWC-TVS and the size of the equivalent histopathological sample correlated (R = 0.406, p = 0.03). Thus, RWC-TVS allows for the detection of DIE and moderate estimation of the nodule sizes and should be practiced during a diagnostic process.