Determinant factors of fertility outcomes after laparoscopic colorectal resection for endometriosis

Fertility preservation in women with endometriosis

BACKGROUND

Endometriosis is a chronic disease that can compromise fertility in up to 30-50% of affected patients, and it is estimated that patients affected by endometriosis represent about 10% of patients undergoing ART treatments. The hypothesized underlying mechanisms explaining infertility are various, but great attention has been given to the relationship between ovarian endometriomas and reduced ovarian reserve.

OBJECTIVE AND RATIONALE

Infertility in patients with endometriosis does not have univocal management, since surgical therapy can increase the chances of natural conception, but at the same time increases the risk of damage to the ovarian reserve. In some cases, IVF procedures should be considered instead of surgery, within a personalized strategy. It has therefore been proposed that patients with endometriosis are eligible for fertility preservation.

SEARCH METHODS

This article is based on a critical review of literature on peer-reviewed article indexing databases including PubMed, Scopus and Medline, using as keywords: 'fertility preservation', 'oocyte vitrification', 'endometriosis', 'endometrioma', 'ovarian reserve' and 'in vitro fertilization'.

OUTCOMES

Data regarding the feasibility of oocyte cryopreservation in patients with endometriosis have increased over recent years, indicating that these patients seem to have the same number of oocytes retrieved and IVF outcomes similar to those who perform fertility preservation for other indications. However, probably due to a reduced ovarian reserve, several cycles of ovarian stimulation may be needed to gather a suitable number of retrieved oocytes per patient. Age, ovarian reserve, and previous ovarian surgery are the main factors affecting the success of fertility preservation. Bilateral endometriomas, a history of unilateral endometrioma surgery with a contralateral recurrence, and preoperative reduced ovarian reserve are the most common indications for fertility preservation. The choice between primary surgery and ART is often complex, requiring a therapeutic strategy tailored to the patient's clinical characteristics and needs, such as age, type and severity of endometriosis lesions, presence of symptoms, surgical history, and desire for pregnancy.

LIMITATIONS REASONS FOR CAUTION

The development of endometriosis-related infertility and the severity of ovarian damage due to endometriosis lesions per se or their surgical treatment are difficult to predict, and data are lacking concerning which subgroups of patients with endometriosis might benefit most from fertility preservation.

WIDER IMPLICATIONS

Women with endometriosis, and in particular women with bilateral ovarian endometriomas or recurrent surgery on the ovaries, should be advised about risk of ovarian reserve damage. Oocyte cryopreservation is an established technique that has been demonstrated as feasible and successful for these patients; however, the specific indications have not yet been established.

STUDY FUNDING/COMPETING INTERESTS

There are no funding sources for the study and no conflicts of interest to declare.

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.

Fertility Preservation in Women with Endometriosis

Several mechanisms have been implicated in the pathogenesis of endometriosis-related infertility. For patients considering surgery, the risk of iatrogenic injury is among the most important factors in the context of fertility preservation, along with age and individual reproductive goals. In the case of endometrioma excision, evidence overwhelmingly demonstrates the negative impact of surgery on ovarian reserve, with significant reductions in antimullerian hormone (up to 30% in unilateral versus up to 44% in bilateral endometriomas). The surgical endometriosis patient should be thoroughly counseled regarding fertility preservation and discussion should include tissue, embryo, and oocyte cryopreservation options. For the latter, data support cryopreservation of 10-15 oocytes in women ≤35 years and over 20 for those >35 years for a realistic chance to achieve one or more live births. When performing surgical interventions for endometriosis, reproductive surgeons should employ fertility-conserving surgical methods to reduce the likelihood of postoperative iatrogenic diminished ovarian reserve.

Minimally invasive surgery for ovarian endometriosis as a mean of improving fertility: Cystectomy vs. CO2 fiber laser ablation what do we know so far?

Minimally invasive surgery emerged in the 1980s as a safe and effective technique which requires smaller incisions and, usually, a shorter hospital stay compared to traditional surgery. Since then, minimally invasive surgery has expanded in many surgical specialties. One of its newest application in gynecology stands in the infertility management of young women with unexplained infertility or suspected endometriosis. In these cases, laparoscopy allows to diagnose and treat the disease aiming to increase at best the chances of spontaneous pregnancy or trough assisted reproductive technology. Nowadays, minimally invasive surgical approach of ovarian endometriosis consists of either laparoscopic cystectomy or ablative techniques such as laparoscopic CO2 fiber laser vaporization. Although cystectomy represents the gold standard according to the latest Cochrane review, some endometriosis experts are worried about its detrimental effect on healthy ovarian parenchyma and suggest preferring a less aggressive approach such as CO2 fiber laser vaporization. The aim of this review is to give an overview of the available evidences about the impact of the two surgical procedures on ovarian reserve markers and pregnancy outcome.

Fertility Outcomes after Surgical Management of Colorectal Endometriosis: A Single-center Retrospective Study

STUDY OBJECTIVE

To assess the pregnancy rate after surgery for colorectal endometriosis.

DESIGN

A retrospective, single-center study performed from January 2014 to December 2019.

SETTING

A university tertiary referral center.

PATIENTS

Patients with the intention to get pregnant younger than the age of 43 years, with or without a history of infertility and who were surgically managed for colorectal endometriosis.

INTERVENTIONS

Complete excision of deeply infiltrating endometriosis.

MEASUREMENTS AND MAIN RESULTS

The postoperative pregnancy rate was assessed. Seventy-seven patients had surgery; their mean age was 32.5 ± 4.4 years. Preoperative documented infertility was present in 77.9% of patients (n = 60). The mean length of history of infertility was 36.2 ± 24.9 months. The procedure was performed by laparoscopic surgery in 92.2% of patients (n = 71). Nonconservative, conservative, and mixed treatment were performed in 66.2% (n = 51), 29.9% (n = 23), and 3.9% of patients (n = 3), respectively. According to the Clavien-Dindo classification, the 3B complication rate was 6.5% (n = 5). The mean follow-up was 46.7 ± 20.6 months. Clinical pregnancies were defined by the presence of intrauterine pregnancy with an embryo with cardiac activity. The postoperative pregnancy rate was 62.3% (n = 48), and 54.2% (n = 26) were spontaneous. The mean number of pregnancies was 1.2 ± 0.4 per patient. In addition, 18.7% of patients (n = 9) got pregnant twice. The mean time from surgery to pregnancy was 13.8 ± 13.1 months. The live birth rate was 89.1% (n = 41). There were no significant differences concerning the prognostic criteria reported in the literature (antimüllerian hormone level, age, presence of adenomyosis). There were no predictive criteria for live births.

CONCLUSION

According to this study, surgery for colorectal endometriosis results in a high postoperative pregnancy rate. Studies with a high level of evidence are needed to determine good candidates for this type of surgery.

Endometriosis fertility index predicts pregnancy in women operated on for moderate and severe symptomatic endometriosis

Endometriosis Fertility Index (EFI) is a clinical staging system created to predict spontaneous pregnancy outcomes in patients with endometriosis. The present study aimed at evaluating the performance of EFI in symptomatic patients, submitted to laparoscopy for moderate and severe endometriosis associated to infertility in a Brazilian population. Seventy-seven women with endometriosis and pelvic pain, who desired to become pregnant, were selected from a tertiary care unit between those operated on between May 2007 and March 2017. All of them were submitted to laparoscopy for the surgical treatment of endometriosis and allowed to attempt natural conception for 36 months or immediately referred to in vitro fertilization (IVF). EFI was calculated according to surgical description and clinical information in medical records. Pregnancy rates and live birth rates after natural conception or IVF are reported and correlated to EFI. Fifty-three women tried natural conception and 24 were referred to IVF. Of the 53 who tried natural conception, 29 achieved pregnancy (54.7%) and 28 had live birth (52.8%). The majority of pregnancies (82.7%) occurred in the first 12 months after surgery and 75% of the patients who became spontaneously pregnant had EFI ≥ 7. Of the 24 patients referred to IVF, 13 became pregnant (54.1%) and 10 had live birth (41.7%). Infertility duration of 36 months or more and the presence of endometrioma increased the probability of having EFI ≤ 5. The overall live birth rate (LBR) for patients with low EFI scores (2-4) was 17% compared with 83.8% for those with higher EFI scores (6-9). EFI predicts pregnancy rates in patients operated on for moderate and severe endometriosis. Scores seem also to predict pregnancy rates after IVF.

Fertility Preservation in Women With Endometriosis

Infertility affects 30% to 50% of women with endometriosis. Women with endometriosis are at risk of decreased ovarian reserve, both because of the pathophysiology of the disease and iatrogenic injury resulting from surgical intervention. Fertility preservation must occur at multiple levels, including careful selection of surgical candidates, avoidance of repeat procedures, and meticulous surgical technique. Fertility preservation with oocyte or ovarian tissue cryopreservation may be considered on an individual basis for women with endometriosis, particularly those at risk of bilateral ovarian injury, such as women with bilateral endometriomas.

Nomogram predicting the likelihood of live-birth rate after surgery for deep infiltrating endometriosis without bowel involvement in women who wish to conceive: A retrospective study

OBJECTIVE

To study the fertility and live birth (LB) rate in women after surgery for deep infiltrating endometriosis (DIE) without bowel involvement and to evaluate the predictive factors of LB after DIE surgery without bowel involvement.

STUDY DESIGN

Retrospective cohort study. A total of 118 women who wished to conceive and who underwent surgery for DIE without bowel involvement were analyzed between January 2006 and December 2014. A multivariate logistic regression analysis of selected factors and a nomogram to predict the subsequent LB rate was constructed.

RESULTS

Thirty-six woman had a LB (30.5%). In multivariate analysis, factors associated with a LB were: age ≤30 years (p = 0.0024), BMI ≤ 25 kg/m² (p = 0.029) and Enzian grade 1 (p < 0.001). These factors were associated to develop a nomogram. Before and after the bootstrap sampling procedure, the predictive model had an AUC of 0.84 (95% CI, 0.82-0.86) and 0.81 (95% CI, 0.79-83), respectively, and showed a good calibration.

CONCLUSIONS

This work presents the originality of describing the fertility and the LB rate after surgery for DIE without bowel involvement with a predictive model. Such tools can help clinicians to support the patient in making an informed decision about fertility treatment options, contributing to the decision-making process by defining simple risk factors of poor LB probability that can help identify good candidates for MAR.

[Surgical management of deep endometriosis with colorectal involvement: CNGOF-HAS Endometriosis Guidelines]

Deep endometriosis with colorectal involvement is considered one of the most severe forms of the disease due to its impact on patients' quality of life and fertility but also by the difficulties encountered by the clinicians when proposing a therapeutic strategy. Although the literature is very rich, evidence based medicine remains poor explaining the great heterogeneity concerning the management of such patients. Surgery therefore remains a therapeutic option. It improves the intensity of gynecological, digestive and general symptoms and the quality of life. Concerning the surgical approach, it appears that laparoscopy should be the first option; the laparoscopic robot-assisted route can also be proposed. The techniques of rectal shaving, discoid resection and segmental resection are the three techniques used for surgical excision of colorectal endometriosis. The parameters taken into account for the use of either technique are: the surgeon's experience, the depth of infiltration of the lesion within the rectosigmoid wall, the lesion size and circumference, multifocality and the distance of the lesion from the anal margin. In the case of deep endometriosis with colorectal involvement, performing an incomplete surgery increases the rate of pain recurrence and decreases postoperative fertility. In case of surgery for colorectal endometriosis, pregnancy rates are similar to those obtained after ART in non-operated patients. Existing data are insufficient to formally recommend first line surgery or ART in infertile patients with colorectal endometriosis. The surgery for colorectal endometriosis exposes to a risk of postoperative complications and recurrence of which the patients should be informed preoperatively.

The Impact of Adenomyosis on Women's Fertility

Until recently, adenomyosis has been associated with multiparity, not impaired fertility. Currently, adenomyosis is diagnosed with increasing frequency in infertile patients since women delay their first pregnancy until their late 30s or early 40s. Although an association between adenomyosis and infertility has not been fully established, based on the available information, recent studies suggested that adenomyosis has a negative impact on female fertility. Several uncontrolled studies with limited data also suggested that treatment of adenomyosis may improve fertility. This article discusses (i) the hypothesis and epidemiology of adenomyosis, (ii) diagnostic techniques, (iii) clinical evidence of correlation between adenomyosis and infertility, (iv) proposed mechanism of infertility in women with adenomyosis, (v) different treatment strategies and reproductive outcomes, and (vi) assisted reproductive technology outcome in women with adenomyosis.

The benefit of adenomyomectomy on fertility outcomes in women with rectovaginal endometriosis with coexisting adenomyosis

Study Objective:

To evaluate the effect of removal of coexisting adenomyosis on fertility outcomes in women with rectovaginal endometriosis.

Design:

A retrospective cohort study.

Setting:

A general hospital.

Patients:

A total of 190 women who underwent laparoscopic nodule excision surgery for rectovaginal endometriosis between April 2007 and December 2012.

Interventions:

Surgical excision of the rectovaginal endometriosis and coexisting uterine adenomyosis. Statistical analysis for fertility outcomes.

Measurement and main results:

A total of 119 women desired postoperative pregnancy. Coexisting adenomyosis was found in 21% of the women. The overall clinical pregnancy rate was 41.2%. The only determining factor associated with a successful pregnancy was “age at surgery”. Clinical pregnancy rates with or without adenomyosis were 36.0% and 42.6%, respectively. We found no significant difference in clinical pregnancy rates between the groups.

Conclusion:

There is a possibility that surgical removal of coexisting adenomyosis positively effects fertility outcomes in women with rectovaginal endometriosis. However, it is also important to note that the age at surgery was a critical factor for successful pregnancy.

Deep infiltrating endometriosis affecting the urinary tract-surgical treatment and fertility outcomes in 2004-2013

Urinary tract endometriosis (UTE) is a rare form of deep infiltrating endometriosis. We studied the operative treatment of UTE and evaluated postoperative recurrences and fertility outcomes. This is a retrospective cohort study of 53 women who underwent operative treatment for UTE in 2004–2013 at Helsinki University Hospital, and were followed-up until the end of 2014. The data were gathered from the hospital’s electronic database. The main outcome measures were complications, reoperations, postoperative pregnancies, and deliveries. Preoperative diagnosis was accurate in 72 % with bladder endometriosis and in 93 % with ureteral disease. Thirty-one (58 %) of the 53 operations were performed via laparoscopy. Postoperative complications requiring re-intervention occurred in five cases (9 %). Five reoperations were performed in four cases due to endometriosis recurrence, only two due to recurrence of UTE (4 %). Twenty-eight women wished for pregnancy; 18 (64 %) of them conceived. Infertility treatment was needed in 20 (71 %) cases. Twelve (75 %) women delivered via cesarean section; intraoperative difficulties occurred in ten (83 %). The complication rate with UTE operations is acceptable and recurrences are rare. Infertility is common, but 57 % of those who wished for a child succeeded. A majority of the deliveries involved unplanned and complicated cesarean section.

The Surgical Treatment of Severe Endometriosis Positively Affects the Chance of Natural or Assisted Pregnancy Postoperatively

OBJECTIVE

To report reproductive outcomes following laparoscopic surgical excision of histologically confirmed r-ASRM stage III-IV endometriosis.

STUDY DESIGN

A retrospective cohort study was performed at the Royal Hospital for Women, a university teaching hospital, Sydney, Australia. Women who had fertility-preserving laparoscopic excision of stage III-IV endometriosis from 1997 to 2009 were contacted regarding reproductive outcomes.

RESULTS

In the study period, 355 women underwent surgery for stage III-IV endometriosis. Follow-up data are available for 253/355 (71%) women. Postoperatively, 142/253 (56%) women attempted to conceive with a conception rate of 104/142 (73%). Confidence intervals for pregnancy for women who were attempting conception (including the nonresponders) range from 104/262 (40%) to 224/262 (85%). Median time to conception was 12 months. No positive prognostic factors for pregnancy were identified on regression analyses.

CONCLUSIONS

These data provide information to women with suspected severe disease preoperatively concerning their likely postoperative fertility outcomes. Ours is a population with severe endometriosis, rather than an infertile population with endometriosis, so caution needs to be applied when applying these data to women with fertility issues alone.

Cecal endometriosis presenting as acute appendicitis

The aim of our paper is to show the diagnosis of Coecal endometriosis as an infrequent reason of right iliac fossa pain. cecal endometriosis manifesting with right lower quadrant pain is difficult to diagnose, and it may even sometimes require laparotomy for diagnosis and treatment. We report here a case of cecal endometriosis causing clinically resembled acute appendicitis. In our patient, a diagnosis of cecal endometriosis was made postoperatively by microscopic examination of excised right colon, and the patient symptoms and general condition were improved after the surgery (open right hemicolectomy and ileocolic anastomosis).

Long-term outcome after laparoscopic bowel resections for deep infiltrating endometriosis: a single-center experience after 900 cases

Background. Laparoscopic bowel resections for endometriosis are safe and effective but only short-term follow-up has been evaluated. In the present study long-term outcome in terms of intestinal and urinary function, fertility, chronic pain, and recurrence was assessed. Materials and Methods. From January 2002 to December 2010 nine hundred patients underwent laparoscopic bowel resection for endometriosis, and on 774 (86%) a questionnaire was administered. Patients were divided into 3 groups on the strength of the operation date. Postoperative diarrhea, constipation, rectal bleeding, tenesmus, dyschezia, dysuria, dyspareunia, fertility, and recurrence of disease were assessed. Results. The median follow-up was 54 months (range 1–120). All the evaluated symptoms significantly improved over time, with P = 0.0001 for dyspareunia, constipation, and pelvic pain and P = 0.004 for diarrhea. Nonsignificant improvement was reported for dysuria and rectal bleeding (with P = 0.452 and P = 0.097, resp.). Conclusions. The present results confirm that bowel resections for endometriosis are correlated with an acceptable complication rate even at long-term follow-up and that symptoms significantly improve over time, except for rectal bleeding and dysuria, the latter associated with a neurological damage.

Uterine adenomyosis and in vitro fertilization outcome: a systematic review and meta-analysis

STUDY QUESTION

Is adenomyosis associated with IVF/ICSI outcome in terms of clinical pregnancy rate?

SUMMARY ANSWER

In a meta-analysis of published data, women with adenomyosis had a 28% reduction in the likelihood of clinical pregnancy at IVF/ICSI compared with women without adenomyosis.

WHAT IS KNOWN ALREADY

Estimates of the effect of adenomyosis on IVF/ICSI outcome are inconsistent.

STUDY DESIGN, SIZE, DURATION

A systematic literature review and meta-analysis were conducted. A Medline search was performed to identify all the comparative studies published from January 1998 to June 2013 in the English language literature on IVF/ICSI outcome in women with and without adenomyosis. Two authors independently performed the literature screening, scrutinized articles of potential interest, selected relevant studies and extracted data. Studies were categorized based on research design.

PARTICIPANTS, SETTING, METHODS

Of the 17 articles assessed in detail, 9 were finally selected based on diagnosis of adenomyosis at magnetic resonance imaging or transvaginal ultrasonography. The quality of studies was evaluated by means of the Newcastle-Ottawa scale. A total of 1865 women were enrolled in the 9 selected studies, 665 of whom in 4 prospective observational studies, and 1200 in 5 retrospective studies. The dichotomous data for clinical pregnancy and secondary outcomes were expressed as risk ratios (RR) with 95% confidence intervals (CIs) and were combined in a meta-analysis using the random-effects model. The heterogeneity Cochrane's Q and the I(2) statistics were calculated. Egger's approach to testing the significance of funnel plot asymmetry was also used.

MAIN RESULTS AND THE ROLE OF CHANCE

The clinical pregnancy rate achieved after IVF/ICSI was 123/304 (40.5%) women with adenomyosis versus 628/1262 (49.8%) in those without adenomyosis. The RR of clinical pregnancy ranged from 0.37 (95% CI, 0.15-0.92) to 1.20 (95% CI, 0.58-2.45), with a significant heterogeneity among studies (I(2) = 56.8%, P = 0.023). Pooling of the results yielded a common RR of 0.72 (95% CI, 0.55-0.95). A funnel plot showed no indication of asymmetry among studies (Egger's test, P = 0.696). In a meta-regression model, no association was observed between prevalence of endometriosis and the likelihood of clinical pregnancy. Three studies reported the pregnancy rate per cycle. The common RR was 0.71 (95% CI, 0.51-0.98; I(2) = 78.1%, P = 0.010). The RR observed in a study with donated oocytes was 0.90 (95% CI, 0.75-1.08). The number of miscarriages per clinical pregnancy was reported in seven studies. A miscarriage was observed in 77/241 women with adenomyosis (31.9%) and in 97/687 in those without adenomyosis (14.1%). The RR of miscarriage ranged from 0.57 (95% CI, 0.15-2.17) to 18.00 (95% CI, 4.08-79.47) (I(2) = 67.7%, P = 0.005). Pooling of the results yielded a common RR of 2.12 (95% CI, 1.20-3.75).

LIMITATIONS, REASONS FOR CAUTION

Qualitative and quantitative heterogeneity among studies was high. At sensitivity analysis, I(2) statistic regarding the main outcome was reduced under the 50% threshold removing one trial, but the resulting confidence interval crossed unity. Also the confidence interval of the common RR of the four studies reporting only one IVF/ICSI cycle included unity. Only part of the studies could be included in the assessment of secondary outcomes.

WIDER IMPLICATIONS OF THE FINDINGS

Adenomyosis appears to impact negatively on IVF/ICSI outcome owing to reduced likelihood of clinical pregnancy and implantation, and increased risk of early pregnancy loss. Screening for adenomyosis before embarking on medically assisted reproductive procedures should be encouraged. The potentially protective role of long down-regulation protocols needs further evaluation. In future studies on the association between adenomyosis and IVF/ICSI outcome, a matched case-control design should be adopted, live birth should be the default primary outcome and only the results regarding the first cycle should be considered.

STUDY FUNDING/COMPETING INTEREST

None.

Feasibility and first long-term results after laparoscopic rectal segment resection and vaginal specimen retrieval for deep infiltrating endometriosis

INTRODUCTION

Radical resection of deep infiltrating endometriosis (DIE), including bladder and bowel resection, provides relief from pain in symptomatic patients. The laparoscopic approach to treatment is well established for bowel resection but normally requires additional abdominal incisions for specimen retrieval. Here we describe our technique of laparoscopically assisted rectal resection and transvaginal specimen retrieval (LARRT) and provide follow-up information on pain scores and complications.

MATERIALS AND METHODS

Retrospective observational monocentric study on all DIE patients with rectal infiltration treated between 2008 and 2010 with LATRR at our department. Follow-up was obtained for at least 3 years, including baseline 1-year and 3-year pain scores.

RESULTS

We identified four patients undergoing LARRT available for follow-up. DIE was confirmed by histology in all cases. There were no intraoperative complications. Two patients had transient postoperative urinary retention, one patient developed recto-vaginal fistula and required transient colostomy. One patient suffered from persistent vaginal dryness. All patients, however, reported persistent pain relief, including at the end of follow-up period.

CONCLUSION

LARRT is a feasible variation of laparoscopic bowel resection for DIE with rectal infiltration. In our study it has promising results with respect to pain control. Larger studies will, however, be required to determine the safety of this procedure.

Gonadotrophin-releasing hormone analogues and endometriosis: current strategies and new insights

BACKGROUND

Endometriosis is an estrogen-dependent chronic inflammatory disease affecting 5% to 10% of women in reproductive age and has been reported also in adolescents. Its main clinical presentations are chronic pelvic pain and infertility.

OBJECTIVE

To provide a comprehensive review of the recently published data concerning the mechanism of action of gonadotrophin-releasing hormone analogues (GnRHas) as well as to analyze their role in the management of endometriosis-associated pain and infertility in addition to its value in adolescent cases. Furthermore, to provide practical recommendations and new insights based on the best available information.

METHODS

Systematic search was performed of the Cochrane Library and Medical Literature Analysis and Retrieval System Online database looking for the different trials, reviews and various guidelines relating to GnRHas usage in the management of endometriosis-associated pain, infertility and in adolescent cases.

RESULTS

From a pathophysiological perspective, there is a growing scientific evidence that GnRHas exert its therapeutic effects by their classical pituitary downregulation and via a direct effect on the endometrial cells themselves. Accordingly, they represent an important medical option for the management of different aspects of this enigmatic disease.

CONCLUSION

GnRHas have a valuable strategic role in treatment of endometriosis-associated pain and infertility as well as in adolescents above 16 years.

Effect of patient selection on estimate of reproductive success after surgery for rectovaginal endometriosis: literature review

The effect of rectovaginal endometriosis on fertility is unclear. Several authors foster radical surgery, including colorectal resection, as a fertility-enhancing procedure. However, interpretation of data is difficult, as the baseline fertility status is often undefined and it is not always possible to discriminate between spontaneous conceptions and those resulting from IVF. A systematic literature review was performed with the aim of defining the pregnancy rate specifically in patients who were infertile before surgery and who sought spontaneous pregnancy. A PubMed search was conducted to identify English language studies published between 2005 and 2011 evaluating reproductive performance after surgery for rectovaginal and rectosigmoid endometriosis. According to the results of the 11 selected studies, the mean post-operative conception rate in all women seeking pregnancy independently of preoperative fertility status and IVF performance was 39% (95% CI 35-43%; 223/571), but dropped to 24% (95% CI 20-28%; 123/510) in infertile patients who sought spontaneous conception (odds ratio 0.50, 95% CI 0.38-0.65%). Patients' selection significantly influences the estimate of the effect of rectovaginal endometriosis excision on infertility. This should be carefully taken into consideration at preoperative counselling. Rectovaginal endometriosis usually is associated with pain symptoms, but the effect of this disease form on fertility is uncertain, as burial of foci beneath rectouterine adhesions with exclusion of the deepest part of the pelvis may limit interference with fertilization processes. Several authors foster radical surgery, including colorectal resection, as a fertility-enhancing procedure. However, interpretation of data is difficult, as the baseline fertility status is often undefined and it is not always possible to discriminate between spontaneous conceptions and those resulting from IVF. A systematic literature review was performed with the aim of defining the pregnancy rate specifically in patients who were infertile before surgery and who sought pregnancy spontaneously. A PubMed search was conducted to identify English language studies published between 2005 and 2011 evaluating reproductive performance after surgery for rectovaginal and rectosigmoid endometriosis. According to the results of the 11 selected studies, the mean post-operative conception rate in all women seeking pregnancy independently of preoperative fertility status and IVF performance was 39% (223/571), but dropped to 24% (123/510) in infertile patients who sought conception spontaneously. The 15% difference is statistically significant. Infertile patients with rectovaginal endometriosis considering surgery, should be carefully informed of the real probability of post-operative conception avoiding generic overestimations.

Fertility after colorectal resection for endometriosis: results of a prospective study comparing laparoscopy with open surgery

OBJECTIVE

To determine whether the surgical route of colorectal resection for endometriosis is a determinant factor for fertility.

DESIGN

Prospective study.

SETTING

Tertiary-care university hospital.

PATIENT(S)

Fifty-two patients with endometriosis were randomly assigned to laparoscopic or open surgery.

INTERVENTION(S)

Laparoscopically assisted vs. open colorectal resection.

MAIN OUTCOME MEASURE(S)

Evaluation of fertility outcomes spontaneously and after assisted reproductive therapy.

RESULT(S)

The mean follow-up was 29 months. Among the 28 patients wishing to conceive, 11 (39.3%) became pregnant. Overall cumulative pregnancy rate at 52 months for these patients was 45.1%. For patients with or without infertility, the cumulative pregnancy rate was 37.6% and 55.6%, respectively, and the cumulative spontaneous pregnancy rate 13.3% and 36.5%, respectively. All the spontaneous pregnancies were observed in the laparoscopy group.

CONCLUSION(S)

This study demonstrates that spontaneous pregnancy is more frequent after laparoscopy compared with open surgery for colorectal endometriosis.