Pain assessment in women with or without endometriosis during the IVF process: a prospective study

RESEARCH QUESTION

How does the typology and effect of pain vary between infertile patients with or without endometriosis during the different stages of the IVF process?

DESIGN

A prospective, monocentric, observational cohort study was conducted at Lille University Hospital between November 2019 and June 2021. The study was proposed to all patients starting an IVF cycle. Pain assessment questionnaires using validated scales (about type of pain, without specific location), were completed by patients at key points during IVF: before starting treatment, at the end of stimulation and on the day of oocyte retrieval.

RESULTS

A total of 278 patients were analysed: 73 patients with endometriosis and 205 without. At the start of the IVF process, patients with endometriosis had higher pain scores than disease-free women (mean numerical scale score 3.47 versus 1.12 [P < 0.0001]) and 17.81% of patients with endometriosis had neuropathic pain. For mental disorders before starting treatment, 22% of patients with endometriosis had suspected or confirmed depression, and 33% had anxiety compared with 8% and 20% in patients without endometriosis, respectively. During IVF, for patients without endometriosis, pain increased significantly between the baseline, the end of stimulation and on the day of retrieval (P ≤ 0.05). In patients with endometriosis, however, pain did not significantly vary during these times.

CONCLUSION

Endometriosis is associated with higher pain scores, but no increase in pain was observed during IVF for these patients. It seems essential to screen and characterize pain phenotypes in all patients before starting treatment and during stimulation to improve pain management.

Management of endometriosis: CNGOF/HAS clinical practice guidelines - Short version

First-line diagnostic investigations for endometriosis are physical examination and pelvic ultrasound. The second-line investigations are: targeted pelvic examination performed by an expert clinician, transvaginal ultrasound performed by an expert physician sonographer (radiologist or gynaecologist), and pelvic MRI. Management of endometriosis is recommended when the disease has a functional impact. Recommended first-line hormonal therapies for the management of endometriosis-related pain are combined hormonal contraceptives (CHCs) or the 52mg levonorgestrel-releasing intrauterine system (IUS). There is no evidence base on which to recommend systematic preoperative hormonal therapy solely to prevent surgical complications or facilitate surgery. After surgery for endometriosis, a CHC or 52mg levonorgestrel-releasing IUS is recommended as first-line treatment when pregnancy is not desired. In the event of failure of the initial treatment, recurrence, or multiorgan involvement, a multidisciplinary team meeting is recommended, involving physicians, surgeons and other professionals. A laparoscopic approach is recommended for surgical treatment of endometriosis. HRT can be offered to postmenopausal women who have undergone surgical treatment for endometriosis. Antigonadotrophic hormonal therapy is not recommended for patients with endometriosis and infertility to increase the chances of spontaneous pregnancy, including postoperatively. Fertility preservation options must be discussed with patients undergoing surgery for ovarian endometriomas.

[Management of endometriosis: CNGOF-HAS practice guidelines (short version)]

First-line investigations to diagnose endometriosis are clinical examination and pelvic ultrasound. Second-line investigations include pelvic examination performed by a referent clinician, transvaginal ultrasound performed by a referent echographist, and pelvic MRI. It is recommended to treat endometriosis when it is symptomatic. First-line hormonal treatments recommended for the management of painful endometriosis are combined with hormonal contraceptives or levonorgestrel 52mg IUD. There is no evidence to recommend systematic preoperative hormonal therapy for the unique purpose of preventing the risk of surgical complications or facilitating surgery. After endometriosis surgery, combined hormonal contraceptives or levonorgestrel SIU 52mg are recommended as first-line therapy in the absence of desire of pregnancy. In case of initial treatment failure, recurrence, or multiple organ involvement by endometriosis, medico-surgical and multidisciplinary discussion is recommended. The laparoscopic approach is recommended for the surgical treatment of endometriosis. HRT may be offered in postmenopausal women operated for endometriosis. In case of infertility related to endometriosis, it is not recommended to prescribe anti-gonadotropic hormone therapy to increase the rate of spontaneous pregnancy, including postoperatively. The possibilities of fertility preservation should be discussed with the patient in case of surgery for ovarian endometrioma.

[Endometriosis medical treatment: Hormonal treatment for the management of pain and endometriotic lesions recurrence. CNGOF-HAS Endometriosis Guidelines]

The available literature, from 2006 to 2017, on hormonal treatment has been analysed as a contribution to the HAS-CNGOF task force for the treatment of endometriosis. Available data are heterogeneous and the general level of evidence is moderate. Hormonal treatment is usually offered as the primary option to women suffering from endometriosis. It cannot be used in women willing to conceive. In women who have not been operated, the first line of hormonal treatment includes combined oral contraceptives (COC) and the levonorgestrel-releasing intra uterine system (52mg LNG-IUS). As a second line, desogestrel progestin only pills, etonogestrel implants, GnRH analogs (GnRHa) with add back therapy and dienogest can be offered. Add back therapy should include estrogens to prevent bone loss and improve quality of life, it can be introduced before the third month of treatment to prevent side effects. The literature does not support preoperative hormonal treatment for the sole purpose of reducing complications or recurrence, or facilitating surgical procedures. After surgical treatment, hormonal treatment is recommended to prevent pain recurrence and improve quality of life. COCs or LNG IUS are recommended as a first line. To prevent recurrence of endometriomas COC is advised and maintained as long as tolerance is good in the absence of pregnancy plans. In case of dysmenorrhea, postoperative COC should be used in a continuous scheme. GnRHa are not recommended in the sole purpose of reducing endometrioma recurrence risk.

Analgesic efficacy of bilateral superficial cervical plexus block administered before thyroid surgery under general anaesthesia

BACKGROUND

The use of regional anaesthesia in thyroid surgery remains controversial. This double-blind, randomized controlled study was conducted to evaluate the analgesic efficacy of bilateral superficial cervical plexus block (BSCPB) performed under general anaesthesia in patients undergoing total thyroidectomy.

METHODS

Eighty-seven consecutive consenting patients were randomized to receive a BSCPB with saline (Group P, n = 29), ropivacaine 0.487% (Group R, n = 29), or ropivacaine 0.487% plus clonidine 5 microg ml(-1) (Group RC, n = 29). Sufentanil was given during the intraoperative period for a 20% increase in arterial mean pressure or heart rate in a patient with a bispectral index between 40 and 60. All patients received 4 g of acetaminophen during the first 24 h after operation. The pain score was checked every 4 h and nefopam was given for pain score >4 on a numeric pain scale.

RESULTS

During surgery, the median sufentanil requirements were significantly reduced in Group RC compared with Groups R and P (0.32 vs 0.47 and 0.62 microg kg(-1); P < 0.0001). After surgery, the number of patients requiring nefopam within 24 h of surgery was significantly lower in Groups R and RC than in Group P (16 and 19 vs 25; P = 0.03). At post-anaesthetic care unit admission, median (range) pain scores were significantly lower in Groups R [3 (0-10)] and RC [3 (0-8)] than in Group P [5 (0-8), P = 0.03]. No major complications of BSCPB occurred during study.

CONCLUSIONS

BSCPB with ropivacaine and clonidine improved intraoperative analgesia. BSCPB with ropivacaine or ropivaciane and clonidine was effective in reducing analgesic requirements after thyroid surgery.