[Laser vaporization of ovarian endometriomas: the impact on the response to gonadotrophin stimulation]

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.

Biomechanical forces and signals operating in the ovary during folliculogenesis and their dysregulation: implications for fertility

BACKGROUND

Folliculogenesis occurs in the highly dynamic environment of the ovary. Follicle cyclic recruitment, neo-angiogenesis, spatial displacement, follicle atresia and ovulation stand out as major events resulting from the interplay between mechanical forces and molecular signals. Morphological and functional changes to the growing follicle and to the surrounding tissue are required to produce oocytes capable of supporting preimplantation development to the blastocyst stage.

OBJECTIVE AND RATIONALE

This review will summarize the ovarian morphological and functional context that contributes to follicle recruitment, growth and ovulation, as well as to the acquisition of oocyte developmental competence. We will describe the changes occurring during folliculogenesis to the ovarian extracellular matrix (ECM) and to the vasculature, their influence on the mechanical properties of the ovarian tissue, and, in turn, their influence on the regulation of signal transduction. Also, we will outline how their dysregulation might be associated with pathologies such as polycystic ovary syndrome (PCOS), endometriosis or premature ovarian insufficiency (POI). Finally, for each of these three pathologies, we will highlight therapeutic strategies attempting to correct the altered biomechanical context in order to restore fertility.

SEARCH METHODS

For each area discussed, a systematic bibliographical search was performed, without temporal limits, using PubMed Central, Web of Science and Scopus search engines employing the keywords extracellular matrix, mechanobiology, biomechanics, vasculature, angiogenesis or signalling pathway in combination with: ovary, oogenesis, oocyte, folliculogenesis, ovarian follicle, theca, granulosa, cumulus, follicular fluid, corpus luteum, meiosis, oocyte developmental competence, preimplantation, polycystic ovary syndrome, premature ovarian insufficiency or endometriosis.

OUTCOMES

Through search engines queries, we yielded a total of 37 368 papers that were further selected based on our focus on mammals and, specifically, on rodents, bovine, equine, ovine, primates and human, and also were trimmed around each specific topic of the review. After the elimination of duplicates, this selection process resulted in 628 papers, of which 287 were cited in the manuscript. Among these, 89.2% were published in the past 22 years, while the remaining 8.0%, 2.4% or 0.3% were published during the 1990s, 1980s or before, respectively. During folliculogenesis, changes occur to the ovarian ECM composition and organization that, together with vasculature modelling around the growing follicle, are aimed to sustain its recruitment and growth, and the maturation of the enclosed oocyte. These events define the scenario in which mechanical forces are key to the regulation of cascades of molecular signals. Alterations to this context determine impaired folliculogenesis and decreased oocyte developmental potential, as observed in pathological conditions which are causes of infertility, such as PCOS, endometriosis or POI.

WIDER IMPLICATIONS

The knowledge of these mechanisms and the rules that govern them lay a sound basis to explain how follicles recruitment and growth are modulated, and stimulate insights to develop, in clinical practice, strategies to improve follicular recruitment and oocyte competence, particularly for pathologies like PCOS, endometriosis and POI.

The effect of laparoscopic excisional and ablative surgery on ovarian reserve in patients with endometriomas: A retrospective study

This study investigates the effect of 2 laparoscopic methods on ovarian reserve in patients of reproductive age with endometriomas.This was a retrospective study performed at a tertiary medical center from Jan 1st to Dec 31st, 2016. Laparoscopic cystectomy (group 1, 46 patients) and laparoscopic ovarian drainage and ablation with bipolar coagulation at low power (group 2, 30 patients) were performed to treat endometriomas larger than 3 cm. Anti-Müllerian hormone was used to assess ovarian reserve before and after surgery.There were no statistically significant differences in patients' baseline clinical characteristics, endometriotic stage, operative time, and follow-up time between the groups. The mean serum anti-Müllerian hormone concentration decreased significantly from 4.25 ng/ml to 3.40 ng/ml in group 1 compared with 4.47 ng/ml to 3.95 ng/ml in group 2 (P  = .04). Pregnancy rates were 71.05% in group 1 and 73.08% in group 2, with a mean follow-up of 30.40 months and 32.35 months (P  > .99), respectively. Although there was no statistical significance, the recurrence rate in group 1 was lower than that in group 2 (4.35% vs 16.67%, respectively; P = .11). The mean diameter of recurrent cysts was 1.75 cm in group 1 and 1.54 cm in group 2 (P = .13).Appropriate laparoscopic electrocautery of the endometrioma wall with a bipolar instrument may be a valid alternative to traditional laparoscopic cystectomy, with less effects on ovarian reserve.

Reproductive, obstetric, and perinatal outcomes of women with adenomyosis and endometriosis: a systematic review and meta-analysis

BACKGROUND

The reproductive impact of adenomyosis and endometriosis is widely researched but the extent of these impacts remains elusive. It has been demonstrated that endometriosis, in particular, is known to result in subfertility but endometriosis and adenomyosis are increasingly linked to late pregnancy complications such as those caused by placental insufficiency. At the molecular level, the presence of ectopic endometrium perturbs the endometrial hormonal, cellular, and immunological milieu, negatively influencing decidualization, placentation, and developmental programming of the embryo. It is unclear if and how such early aberrant reproductive development relates to pregnancy outcomes in endometriosis and adenomyosis.

OBJECTIVE AND RATIONALE

The aims of this systematic review and meta-analysis were to (i) investigate the association of adenomyosis and endometriosis with fertility, obstetric, and neonatal outcomes of women through both assisted reproduction and natural conception and (ii) determine whether endometriosis disease subtypes have specific impacts on different stages of the reproductive process.

SEARCH METHODS

A systematic literature review of NHS evidence electronic databases and the Cochrane database identified all comparative and observational studies between 1980 and December 2018 in any language on adenomyosis and endometriosis with fertility, obstetric, and neonatal outcomes (23 search terms used). A total of 104 papers were selected for data extraction and meta-analysis, with use of Downs and Black standardized checklist to evaluate quality and bias.

OUTCOMES

We found that endometriosis consistently leads to reduced oocyte yield and a reduced fertilization rate (FR), in line with current evidence. Milder forms of endometriosis were most likely to affect the fertilization (FR OR 0.77, CI 0.63-0.93) and earlier implantation processes (implantation rate OR 0.76, CI 0.62-0.93). The more severe disease by American Society for Reproductive Medicine staging (ASRM III and IV) influenced all stages of reproduction. Ovarian endometriosis negatively affects the oocyte yield (MD -1.22, CI -1.96, -0.49) and number of mature oocytes (MD -2.24, CI -3.4, -1.09). We found an increased risk of miscarriage in both adenomyosis and endometriosis (OR 3.40, CI 1.41-8.65 and OR 1.30, CI 1.25-1.35, respectively), and endometriosis can be associated with a range of obstetric and fetal complications including preterm delivery (OR 1.38, CI 1.01-1.89), caesarean section delivery (OR 1.98 CI 1.64-2.38), and neonatal unit admission following delivery (OR 1.29, CI 1.07-1.55).

WIDER IMPLICATIONS

Adenomyosis and the subtypes of endometriosis may have specific complication profiles though further evidence is needed to be able to draw conclusions. Several known pregnancy complications are likely to be associated with these conditions. The complications are possibly caused by dysfunctional uterine changes leading to implantation and placentation issues and therefore could potentially have far-reaching consequences as suggested by Barker's hypothesis. Our findings would suggest that women with these conditions should ideally receive pre-natal counselling and should be considered higher risk in pregnancy and at delivery, until evidence to the contrary is available. In order to expand our knowledge of these conditions and better advise on future management of these patients in reproductive and maternal medicine, a more unified approach to studying fertility and reproductive outcomes with longer term follow-up of the offspring and attention to the subtype of disease is necessary.

The effect of surgical management of endometrioma on the IVF/ICSI outcomes when compared with no treatment? A systematic review and meta-analysis

Objective

To assess the impact of surgical management of endometrioma on the outcome of assisted reproduction treatment (ART).

Design

A systematic review and meta-analysis.

Setting

Department of reproductive medicine at teaching university hospital, UK.

Patients

Subfertile women with endometrioma undergoing ART.

Interventions

Surgical removal of endometrioma or expectant management.

Main outcome measures

Clinical pregnancy rate, pregnancy rate, live birth rate, number of oocytes retrieved and number of embryos available and ovarian response to gonadotrophins.

Results

An extensive search of electronic databases for articles published from inception to September 2016 yielded 11 eligible studies for meta-analysis. Meta-analysis was conducted comparing surgery versus no treatment of endometrioma. There were no significant differences in pregnancy rate per cycle, clinical pregnancy rate and live birth rate between women who underwent surgery for endometrioma and those who did not.

Conclusion

Current evidence suggests that women with endometriosis-related infertility have similar cycle outcomes to other patients going through ART. It is pertinent for clinicians to assess the risks of surgical intervention on ovarian reserve prior to initiating therapy.

Treatment efficacy for pain complaints in women with endometriosis of the lesser pelvis after laparoscopic electroablation vs. CO2 laser ablation

Endometriosis is a chronic disease affecting mainly women of the reproductive age. Its most common manifestations include impaired fecundity, pelvic pain, and dyschezia. Laparoscopic removal of endometriotic foci remains to be the gold standard for the treatment of endometriosis. More effective techniques of endoscopic approach-among others, laser application-are continually being developed. The aim of the study was to evaluate the efficacy of laparoscopic treatment with the use of CO2 laser ablation vs. electroablation with regard to pain complaints in the affected patients. The study included 48 women (aged 22-42) with varying degrees of endometriosis of the lesser pelvis. The Numeric Rating Scale (NRS) was used to evaluate pain intensity before the surgery in all patients, followed by either laser ablation or electroablation of the endometriotic foci. The results of the laparoscopic treatment were monitored after 3 and 6 months postoperatively. p value of 0.05 was considered to be statistically significant. Patients from both groups reported less intensive pain before/during menstruation (dysmenorrhea) 6 months postoperatively, with more distinct tendency in the electroablation group (p = 0.004) as compared to the laser ablation group (p = 0.025). Despite the initial improvement reported at the 3-month checkup (p = 0.008), 6 months postoperatively, a statistically significant increase in pain intensity was noted in both groups (p = 0.016 and p = 0.032 for CO2 laser ablation and electroablation, respectively). Both surgical methods seem to be effective only in the treatment of endometriosis-related dysmenorrhea, whereas the intensity of other pain complaints (dyspareunia, dysuria, dyschezia, pelvic pain syndrome (PPS)) has remained on the same level.

Impact of endometriosis and its staging on assisted reproduction outcome: systematic review and meta-analysis

OBJECTIVE

To evaluate whether the presence or severity of endometriosis affects the outcome of assisted reproductive techniques (ART).

METHODS

In this systematic review, all studies comparing the outcome of ART in women with and those without endometriosis, or at different stages of the disease, were considered eligible. We used either risk ratio (RR) or mean difference (MD) and their 95%CIs for comparisons. The primary outcome was live birth; the secondary outcome was clinical pregnancy. Miscarriage and the number of oocytes retrieved were examined as additional outcomes.

RESULTS

We included 92 studies in the review and 78 in the meta-analysis: 20,167 women with endometriosis were compared with 121,931 women without endometriosis, and 1703 women with Stage-III/IV endometriosis were compared with 2227 women with Stage-I/II endometriosis. The following results were observed for the comparison of women with endometriosis vs women without endometriosis: live birth, RR = 0.99 (95%CI, 0.92-1.06); clinical pregnancy, RR = 0.95 (95%CI, 0.89-1.02); miscarriage, RR = 1.31 (95%CI, 1.07-1.59); number of oocytes retrieved, MD = -1.56 (95%CI, -2.05 to -1.08). The following results were observed for the comparison of women with Stage-III/IV vs Stage-I/II endometriosis: live birth, RR = 0.94 (95%CI, 0.80-1.11); clinical pregnancy, RR = 0.90 (95%CI, 0.82-1.00); miscarriage, RR = 0.99 (95%CI, 0.73-1.36); number of oocytes retrieved, MD = -1.03 (95%CI, -1.67 to -0.39).

CONCLUSIONS

Women with endometriosis undergoing ART have practically the same chance of achieving clinical pregnancy and live birth as do women with other causes of infertility. No relevant difference was observed in the chance of achieving clinical pregnancy and live birth following ART when comparing Stage-III/IV with Stage-I/II endometriosis. The quality of the evidence for the additional examined outcomes was very low, not allowing meaningful conclusions to be drawn.

Ultrasound-guided interventional therapy for recurrent ovarian chocolate cysts

The aim of this study was to determine the effectiveness of ultrasound-guided interventional therapy in the treatment of postoperative recurrent chocolate cysts. The 198 patients enrolled in this study were divided into three groups. In group 1, the saline washing group, the cavity of the cyst was washed thoroughly with warm saline. In group 2, the ethanol short-time retention group, after washing with saline, the cyst was injected with 95% ethanol with a volume of half of the fluid aspirated from the cyst. Ten minutes later, the rest of the ethanol was aspirated. In group 3, the ethanol retention group, the procedures were the same as with the ethanol short-time retention group, except that 95% of the ethanol was retained in the cyst. An ultrasound examination was performed in the third, sixth and 12th months after therapy. The chocolate cyst cure rate was significantly higher in the ethanol retention group (96%, 66/69) than in the ethanol short-time retention group (82%, 56/68) and no case was cured in the first group (saline washing). We conclude that ultrasound-guided injection and 95% ethanol retention are an effective therapy for the treatment of postoperative recurrent chocolate cysts.

Laparoscopic management of endometriomas using a combined technique of excisional (cystectomy) and ablative surgery

OBJECTIVE

To describe and evaluate a new technique of laparoscopic treatment of endometriomas that combines excisional and ablative surgery.

DESIGN

Descriptive and prospective study.

SETTING

Gynecology research unit in a university hospital.

PATIENT(S)

Fifty-two women under 35 years of age presenting for infertility and/or pelvic pain with endometriomas larger than 3 cm were included in the study. None had undergone any surgery for endometriosis.

INTERVENTION(S)

A large part of the endometrioma wall was first excised according to the cystectomy technique. After this first step, CO(2) laser was used to vaporize the remaining 10%-20% of the endometrioma wall close to the hilus.

MAIN OUTCOME MEASURE(S)

The feasibility of this new technique was assessed. Ovarian volume and antral follicle count (AFC) were compared between operated ovaries and nonoperated ovaries of patients with endometriosis and controls (women with male factor infertility).

RESULT(S)

The combined technique was possible in all cases. The volume of the ovary after the combined technique was similar to that of the contralateral normal ovary, as well as to that observed in infertile women without endometriosis presenting for male factor infertility. The AFC on day 2-5 showed the same number of antral follicles in all subgroups. Histopathology of the excised part of the endometrioma revealed the presence of follicles in only one case (2%). The pregnancy rate was 41% at a mean follow-up of 8.3 months. Recurrence of a small endometrioma was observed in only one case (2%).

CONCLUSION(S)

The combined technique (stripping and ablation) has proved not to be deleterious to the ovary.

The value of two-step operative laparoscopy with interval pituitary suppression in the treatment of infertility caused by severe endometriosis

PURPOSE OF REVIEW

To appraise a new approach to laparoscopic surgery for infertility caused by advanced endometriosis.

RECENT FINDINGS

Endometriosis is a common systemic and local disease with altered peritoneal function, which requires both systemic and local treatment. Medication alone cannot improve infertility, and laparoscopic treatment, particularly in severe endometriosis, has a high recurrence rate and is often limited by technical difficulties. Novel treatment strategies have therefore to be sought, especially in women who do not want in-vitro fertilization as a first option, either because they suffer from pain in addition to infertility or want to enhance their fertility over many cycles.

SUMMARY

Two-step operative laparoscopy with interval pituitary suppression by means of gonadotrophin-releasing hormone analogues reduces the extent of endometriosis, as classified by the American Fertility Association, and appears to be a promising method of achieving optimal cytoreduction and facilitating complicated surgery in severe endometriosis, while protecting the ovary from unnecessary trauma. A large-scale well-designed study is needed to confirm that this treatment leads to improved pregnancy rates.

La stérilité par endométriose

From the literature, the crucial knowledge were drawn among endometriosis related infertility. Endometriosis is an important factor of infertility in minimal or light stages and a major one in mild or moderate stages. Thus, a laparoscopy must be performed to confirm endometriosis when suggestive clinical or biological signs exist. In absence of them, laparoscopy can be delayed after intra-uterine inseminations (IUI). The first line treatment is laparoscopic surgery. Its efficacy is proven. It is useless to prescribe a post-operative medical treatment (GnRH analogues). Surgery leads to 25 to 40% of deliveries. It is dependant on age, infertility duration, tubo-ovarian adhesion and tubes involvement. But, surgery can be avoided and the patient is directly referred to In Vitro Fertilization (IVF) when the lesions extension is so important that surgery exposes to complications or when there is a permanent other indication for IVF (severe male infertility). When infertility persists 6 to 12 months after surgery and without patent recurrence, ovulation stimulations and IUI are performed as the second line treatment. After IUI failure, or in case of recurrence, IVF must be applied. A second surgery is not recommended. The IVF results are not impaired by the presence of endometriosis and even of endometriomas. Thus, it is useless to operate again endometriosis before IVF. In opposition, in severe stages or in cases of recurrence, a pre-IVF medical treatment (GnRH analogues) improves the results. IVF do not increased the risk of endometriosis acute growth. In case of infertility and pain, infertility is considered as the first target. But medical treatment can be prescribed between the IVF attempts.

Long-term pituitary down-regulation before in vitro fertilization (IVF) for women with endometriosis

BACKGROUND

Women with endometriosis who are treated with in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) have a lower pregnancy rate compared to women with tubal factor infertility. It has been suggested that the administration of gonadotrophin releasing hormone (GnRH) agonists for a few months prior to IVF or ICSI increases the pregnancy rate.

OBJECTIVES

To determine the effectiveness of administering GnRH agonists for three to six months prior to IVF or ICSI in women with endometriosis.

SEARCH STRATEGY

We used computer searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, the National Research Register (NRR) and the MDSG Specialised Register of controlled trials. We handsearched proceedings of annual meetings of the American Society for Reproductive Medicine (ASRM) and the European Society for Human Reproduction and Embryology (ESHRE). We reviewed lists of references in original research and review articles. We contacted experts in various countries to identify unpublished trials.

SELECTION CRITERIA

We included randomised controlled trials using any GnRH agonist prior to IVF or ICSI to treat women with any degree of endometriosis diagnosed by laparoscopy or laparotomy

DATA COLLECTION AND ANALYSIS

Two independent review authors abstracted data (HNS and JGV). We sent e-mails to investigators to seek additional information. We assessed the validity of each study using the methods suggested in the Cochrane Handbook. The data were checked by the third review author (SD) and any disagreement was resolved by arbitration with the fourth review author (AA). We generated 2 x 2 tables for principal outcome measures. The Peto-modified Mantel-Haenszel technique was used to calculate odds ratios (OR) and assess statistical heterogeneity between studies.

MAIN RESULTS

Three randomised controlled trials (with 165 women) were included. The live birth rate per woman was significantly higher in women receiving the GnRH agonist compared to the control group (OR 9.19, 95% CI 1.08 to 78.22). However, this was based on one trial reporting "viable pregnancy" only. The clinical pregnancy rate per woman was also significantly higher (three studies: OR 4.28, 95% CI 2.00 to 9.15). The information on miscarriage rates came from two trials with high heterogeneity and, therefore, results of the meta-analysis were doubtful. The included studies provided insufficient data to investigate the effects of administration of GnRH agonists on multiple or ectopic pregnancies, fetal abnormalities or other complications.

AUTHORS' CONCLUSIONS

The administration of GnRH agonists for a period of three to six months prior to IVF or ICSI in women with endometriosis increases the odds of clinical pregnancy by fourfold. Data regarding adverse effects of this therapy on the mother or fetus are not available at present.

Endométriome ovarien associé à une infertilité : quelle est la place de l'abstention thérapeutique?

Ovarian endometrioma is not infrequently encountered in infertile patients. Its etiopathogeny, its relations with attributed symptoms and the recommanded treatment to apply, are still debated. Various therapeutic tools are available, such as abstention, ultrasonographically guided aspiration and drainage, and surgery. Each option carries specific advantages and disadvantages. Ultrasonographically guided aspiration bears infectious risks. Among various proposed surgical procedures, cystectomy appears to offer the best performances. Results of IVF are slightly or not altered, neither by an ovarian endometrioma, nor by previous surgery, except in case of iterative surgery or if operated lesions were very severe. Laparoscopic surgery is still the first line treatment in many cases. Abstention can be applied in particular circumstances. Ultrasonographically guided aspiration needs to be further evaluated.

Surgical management of endometriosis

The efficacy of medical and surgical treatment of endometriosis-associated infertility and pelvic pain is a source of ongoing controversy. Complete resolution of endometriosis is not yet possible and current therapy has three main objectives: (1) to reduce pain; (2) to increase the possibility of pregnancy; and (3) to delay recurrence for as long as possible. It is possible that a consensus will never be reached on the optimal treatment of minimal and mild endometriosis. In case of moderate and severe endometriosis-associated infertility, the combined approach (operative laparoscopy with a gonadotropin-releasing hormone (GnRH) agonist) should be considered as 'first-line' treatment. The mean pregnancy rate of 50% reported in the literature following surgery provides scientific proof that operative treatment should first be undertaken to give our patients the best chance of conceiving naturally. In case of rectovaginal adenomyotic nodules, surgery must be considered as first-line therapy, medical therapy being relatively in-efficacious.