Ovarian endometriosis: from pathogenesis to surgical treatment

Laparoscopic sclerotherapy for ovarian endometriomas during surgery for deep endometriosis: Outcomes of a 134-patient cohort

OBJECTIVE

To evaluate postoperative fertility outcomes and recurrence rates in patients undergoing laparoscopic ethanol sclerotherapy for endometriomas, combined with the resection of deep endometriosis lesions.

METHODS

A retrospective cohort study was conducted at the Franco-European Multidisciplinary Endometriosis Institute (IFEMEndo), Clinique Tivoli-Ducos, Bordeaux, France. The study included 134 patients who underwent laparoscopic surgical resection of deep endometriosis lesions and ethanol sclerotherapy for endometriomas ≥40 mm, between October 2019 and September 2023. The procedure involved aspiration of cyst contents followed by 96% ethanol instillation. The main outcomes measured were fertility rates, endometrioma recurrence, anti-Müllerian hormone (AMH) levels, and postoperative complications.

RESULTS

The mean patient age was 31.8 ± 4.6 years, with 39 (29%) experiencing infertility. Preoperative AMH levels averaged 2.96 ± 2.02 ng/mL and decreased significantly postoperatively (mean difference 1.1 ng/mL, P = 10-8). Severe postoperative complications occurred in 4.5% of patients, none attributed to ethanol sclerotherapy. After surgery, 78 patients expressed a desire to conceive and 45 (57%) achieved pregnancy, with 19 (42%) being spontaneous. The mean time to pregnancy was 13 ± 9 months. Cumulative pregnancy rates were 55.5% at 24 months and 78.8% at 36 months. Predictors of pregnancy included higher preoperative AMH levels (hazard ratio [HR] 1.35, P = 0.008) and absence of prior abdominal surgery (HR 0.32, P = 0.007). Recurrence of endometriomas was observed in 17 (16.5%) patients over a median follow-up of 23 months.

CONCLUSION

In this cohort of patients treated with laparoscopic ethanol sclerotherapy during resection surgery for deep endometriosis, the procedure was safe, with satisfactory pregnancy and recurrence rates comparable to other ablative techniques.

Conservative endometrioma surgery: The combined technique versus CO2-laser vaporization only (BLAST: Belgium LAser STudy): Clinical protocol for a multicenter randomized controlled trial

BACKGROUND

The surgical management of endometrioma(s) remains challenging. Although laparoscopic surgery is a well-established treatment of endometrioma(s), caution is required to minimize ovarian damage. Several surgical techniques have been described to treat endometrioma(s): classical cystectomy, ablative techniques, or a combination of both. As cystectomy is strongly associated with a reduction in ovarian reserve, this randomized controlled trial (RCT) aims to determine to what extent the two other surgical procedures may affect ovarian reserve by comparing changes in serum anti-Müllerian hormone (AMH) levels concentrations after each type of surgery.

METHODS

This is a multicenter, non-blinded, RCT with parallel groups (group 1 (combined technique) versus group 2 (CO2 laser vaporization only)) and allocation 1:1. Four Belgian centers will be involved. Main inclusion criteria are symptomatic patients (pain and/or infertility), 18-40 years (both inclusive) with an endometriotic cyst (mean diameter of ≥ 2.5 cm and ≤ 8 cm) and AMH level ≥ 0.7 ng/mL. Suspicion of malignancy, a contralateral endometrioma of > 2 cm, use of gonadotrophin-releasing hormone (GnRH) analogues around timing of surgery or previous oophorectomy are exclusion criteria. The primary aim is the evaluation of the difference in serum AMH levels between baseline and 3 months postoperatively (or delta AMH). The secondary outcomes include differences in AMH levels at 6 and 12 months postoperatively, cyst recurrence rate, evolution of pain pattern and fertility outcomes.

DISCUSSION

The present study will help us to answer the question on which surgical technique for endometrioma(s) has the most favorable outcome in patients wishing to preserve their reproductive potential.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT04151433. Registered on November 5th, 2019.

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.

Comparison of ovarian reserve after laparoscopic cystectomy in patients with ovarian endometriosis differ in cyst size: A systematic review and meta-analysis

BACKGROUND

Whether cyst size affects ovarian reserve before and after surgery remains controversial.

OBJECTIVE

The objective of this study is to determine whether cyst size causes differences in pre- and post-ovarian reserve impairment among patients with endometrioma.

SEARCH STRATEGY

PubMed, Embase, Web of Science, Cochrane Library, and China National Knowledge Infrastructure were searched from inception to October 13, 2023.

SELECTION CRITERIA

We included prospective studies comparing the ovarian reserve parameters of patients with endometrioma preoperatively and at different time points postoperatively between large and small groups, determined by self-defined cut-off values in eligible studies.

DATA COLLECTION AND ANALYSIS

Bias was assessed using the Newcastle-Ottawa Scale. Standardized mean differences (SMD) and 95% confidence intervals (CIs) were used for outcome measures.

MAIN OUTCOME MEASURE(S)

The main outcome measures are serum anti-Müllerian hormone (AMH) and antral follicle count (AFC) preoperatively and at different time points postoperatively (primary and secondary aims).

MAIN RESULTS

Seven trials (603 participants) were included, all of which qualified for meta-analysis. Irrespective of the cut-off values, the SMD showed that the serum AMH level was significantly lower in large groups at 1 month postoperatively (SMD = -0.515 ng/mL, 95% CI [-0.858, -0.172], P = 0.003,I 2 $$ {I}^2 $$ = 44.3%). Subgroup analyses indicated that when the cut-off values were limited to 5 cm in diameter, the AMH levels were significantly lower in large groups (SMD = -0.822 ng/mL, 95% CI [-1.605, -0.039], P = 0.040,I 2 $$ {I}^2 $$ = 58.3%) 1 month after the surgery, and when cut-off values were limited to 7 cm, even at 3 months postoperatively, the serum AMH levels of patients with large endometrioma were still significantly lower than those with small endometrioma (SMD = -0.531 ng/mL, 95% CI [-0.818, -0.245], P = 0.000,I 2 $$ {I}^2 $$ = 0.0%). However, when cut-off values were not limited, the serum AMH levels did not differ significantly (P > 0.05) between the groups preoperatively and at 3, 6, and 12 months postoperatively. Additionally, there were no significant differences (P > 0.05) in the AFC between the groups preoperatively and 1 month postoperatively.

CONCLUSION

AMH in patients with different endometrioma sizes recovered to the same level at 6 months postoperatively. Our study provides guidance for the clinical prognostic assessment of patients with large endometriomas after laparoscopic cystectomy.

SYSTEMATIC REVIEW REGISTRATION

CRD42023481967(PROSPERO).

Upregulated let-7 expression in the follicular fluid of patients with endometriomas leads to dysfunction of granulosa cells through targeting of IGF1R

STUDY QUESTION

What molecular mechanisms underlie the decline in ovarian reserve as the number and quality of oocytes decrease in patients with ovarian endometriomas (OEM)?

SUMMARY ANSWER

Elevated expression of the let-7 micro(mi)RNAs in the follicular microenvironment of OEM-affected ovaries targets the expression of type 1 insulin-like growth factor receptor (IGF1R) in granulosa cell (GC) and disrupts their proliferation, steroid hormone secretion levels, adenosine triphosphate (ATP) energy metabolism, and reactive oxygen species (ROS) oxidative stress levels.

WHAT IS KNOWN ALREADY

Patients with OEM exhibit diminished ovarian reserve, characterized by reduced oocyte quantity and quality. Fibrotic changes in the ovarian tissue surrounding the OEM create a disruptive microenvironment for follicular growth and development.

STUDY DESIGN, SIZE, DURATION

This is a cross-sectional study aimed to elucidate the molecular mechanisms underlying the impact of OEM on follicular development. Initially, miRNA expression profiles in follicular fluid (FF) samples were sequenced from patients with infertility related to OEM (N = 3) and male factor (MF) infertility (N = 3), with the latter serving as the control group. Differentially expressed miRNAs were validated in additional samples from each group (N = 55 in OEM group and N = 45 in MF group) to confirm candidate miRNAs. The study also investigated indicators associated with GCs dysfunction in vitro on rat GCs. Subsequently, rat models of OEM were established through endometrial allogeneic transplantation, and fertility experiments were conducted to assess the let-7/IGF1R axis response to OEM in vivo. Patient samples were collected between May 2018 and April 2019, and the mechanistic study was conducted over the subsequent three years.

PARTICIPANTS/MATERIALS, SETTING, METHODS

FF and GC samples were obtained from infertile patients undergoing IVF treatment for OEM and MF related infertility. miRNA expression profiles in FF samples were analyzed using second-generation high-throughput sequencing technology, and candidate miRNAs were validated through quantitative PCR (qPCR). In the in vitro experiments conducted with rat GCs, cell proliferation was assessed using the CCK-8 assay, while steroid hormone concentrations were measured using chemiluminescence. ATP content was determined with an ATP assay kit, and levels of ROS were quantified using flow cytometry. A dual luciferase reporter gene assay was employed to identify the target gene of let-7 based on the construction of a IGF1R reporter gene plasmid using 293T cells. Western blotting was utilized to evaluate the expression of IGF1R in GCs, as well as its downstream proteins, and changes in signaling pathways following let-7 agomir/antagomir transfection and/or Igf1r silencing. In the in vivo OEM rat models, alterations in ovarian structure and cyst morphology were observed using hematoxylin and eosin staining. The expressions of let-7 and Igf1r in GCs were evaluated through qPCR, while variations in IGF1R expression were investigated with immunohistochemistry.

MAIN RESULTS AND THE ROLE OF CHANCE

The cohort of patients with ovarian OEM in this study exhibited significantly decreased antral follicle counts, oocyte retrieval numbers, and normal fertilization rates compared to the control group with MF. The expression of the let-7 miRNA family was markedly upregulated in the FF and GCs of OEM patients. Transfection of rat GCs with let-7 agonists diminished the functions of GCs, including disrupted cell proliferation, mitochondrial oxidative phosphorylation, and steroid hormone secretion, while transfection of rat GCs with let-7 antagonists caused the opposite effects. Luciferase reporter gene experiments confirmed that let-7 complementarily bound to the 3'-untranslated regions of IGF1R. Stimulation of let-7 expression in rat GCs led to a significant decrease in IGF1R expression, while inhibition of let-7 increased IGF1R expression. The expression of IGF1R in the GCs of OEM patients was also significantly reduced compared to MF patients. Silencing of Igf1r led to the dysfunction of GCs, similar to the effects of let-7 agonization, as demonstrated by the downregulation of key proteins involved in cell proliferation (CCND2 and CCND3) and oestradiol synthesis, as well as an increase in progesterone synthesis (StAR), while implicating the PI3K-Akt and MAPK signaling pathways. The antagonistic effect of let-7 on GCs was ineffective when Igf1r was silenced. Conversely, the agonistic effect of let-7 on GCs could be reversed by stimulation with the IGF1R ligand IGF-1. These findings suggested that let-7 regulated the proliferation, differentiation, and ATP synthesis of GCs through targeting IGF1R. The OEM rat model demonstrated alterations in ovarian morphology and structure, along with reduced fertility. Let-7 expression was significantly upregulated in GCs of OEM rats compared to normal rats, while Igf1r and IGF1R expression in pre-ovulatory follicular GCs were notably downregulated, supporting the notion that elevated let-7 expression in the follicular microenvironment of OEM inhibited IGF1R, leading to abnormal GC function and impacting fertility at the molecular level.

LARGE SCALE DATA

N/A.

LIMITATIONS, REASONS FOR CAUTION

The synthesis and secretion mechanisms of steroid hormones are intricate and complex. Some enzymes that regulate oestrogen synthesis also play a role in progesterone synthesis. Moreover, certain receptors can respond to multiple hormone signals. Therefore, in this study, the expression patterns of key enzymes such as CYP17A, CYP11A1, HSD3B2, StAR, and receptors including AR, LHCGR, FSHR, ESR2, might be influenced by various factors and might not demonstrate complete consistency.

WIDER IMPLICATIONS OF THE FINDINGS

Future research will concentrate on investigating the potential impact of ovarian stromal cells on the external microenvironment of follicle growth. Additionally, screening for small molecule drugs that target let-7 and IGF1R actions can be conducted to intervene and modify the ovarian microenvironment, ultimately enhancing ovarian function.

STUDY FUNDING/COMPETING INTEREST(S)

This study received funding from the National Natural Science Foundation of China (grant number 82301851 to L.B.S., grant numbers U23A20403 and U20A20349 to S.Y.Z., and grant number 82371637 to Y.D.D.) and the Natural Science Foundation of Zhejiang Province (grant LTGY23H040010 to F.Z.). The authors have no conflicts of interest to declare.

Recurrence after surgery for endometrioma: a systematic review and meta-analyses

IMPORTANCE

Endometriosis is an inflammatory disease, with different forms of expression and a variety of complaints. An endometrioma, an ovarian cyst with endometrium-like lining, is one of the most common expressions of abdominal endometriosis. These endometriomas can, in addition to medical treatment, be treated surgically. After surgery, hormonal therapy is still frequently used for the treatment of endometriosis in general and prevention of recurrence of endometriomas specifically. However, not all women want or can receive postoperative hormonal treatment. It is important for this group to determine the risk of anatomical recurrence of ovarian endometrioma after surgery for an endometrioma.

OBJECTIVE

To determine the recurrence rate for surgically treated endometrioma without postoperative hormonal treatment.

DATA SOURCES

We performed a systematic literature review and meta-analyses, according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. MEDLINE, Embase, and the Cochrane library were searched until May 2023. The literature search was limited to women with endometrioma who received surgical treatment without postoperative hormonal treatment.

STUDY SELECTION AND SYNTHESIS

A distinction was made in study design including randomized controlled trials (RCTs) and cohort and retrospective studies. For assessment of risk of bias, the Cochrane Handbook for Systematic Reviews of Interventions and Risk of Bias in Non-randomized Studies - of Interventions assessment tool were used.

MAIN OUTCOMES

The outcome measure included in this review was endometrioma recurrence.

RESULTS

We screened 5,367 articles, of which 97 were systematically reviewed and 55 were included in this systematic review. Twelve of these were RCTs, 11 were prospective cohort studies, and 32 were retrospective studies. Nine RCTs had a low risk of bias. For non-RCTs, only 3 studies had a low risk of bias. Data of 23 studies were pooled in meta-analyses, performed for follow-up periods of 3, 6, 12, and 24 months. These studies showed recurrence rates of 4%, 14%, 17%, and 27%, respectively.

CONCLUSION AND RELEVANCE

In the meta-analysis, at 24 months after surgery, the endometrioma recurrence rate showed a weighted mean of up to 27%. In this study, we aimed to determine the recurrence rate of endometrioma after surgical treatment in women without postoperative hormonal treatment use. The recurrence rates were up to 27%.

REGISTRATION NUMBER

CRD42020216541.

Endometrioma surgery: Hit with your best shot (But know when to stop)

Ovarian endometriomas (OEs) are commonly detected by ultrasound in individuals affected by endometriosis. Although surgery was widely regarded in the past as the gold standard for treating OEs, especially in the case of large cysts, the surgical management of OEs remains debated. Firstly, OEs often represent the "tip of the iceberg" of underlying deep endometriosis, and this should be considered when treating OEs to ameliorate patients' pain for focusing on the surgical objectives and providing better patient counseling. In the context of fertility care, OEs may have a detrimental effect on ovarian reserve through structural alterations, inflammatory responses, and oocyte reserve depletion. Conversely, the surgical approach may exacerbate the decline within the same ovarian reserve. While evidence suggests no improvement in in-vitro fertilization (IVF) outcomes following OE surgery, further studies are needed to understand the impact of OE surgery on spontaneous fertility. Therefore, optimal management of OEs is based on individual patient and fertility characteristics such as the woman's age, length of infertility, results of ovarian reserve tests, and surgical background. Among the available surgical approaches, cystectomy appears advantageous in terms of reduced recurrence rates, and traditionally, bipolar coagulation has been used to achieve hemostasis following this approach. Driven by concerns about the negative impact on ovarian reserve, alternative methods to obtain hemostasis include suturing the cyst bed, and novel methodologies such as CO2 laser and plasma energy have emerged as viable surgical options for OEs. In instances where sonographic OE features are non-reassuring, surgery should be contemplated to obtain tissue for histological diagnosis and rule out eventual ovarian malignancy.

Ovarian endometrioma: a report of a pediatric case diagnosed prior to menstruation

BACKGROUND

Ovarian endometriomas (OEs) are rarely found in the pediatric population, especially before menstruation. We report a 6-year-old girl who was postoperatively diagnosed with OE before menstruation.

CASE PRESENTATION

A 6-year-old girl presented to a local pediatrician with abdominal pain and vomiting. Abdominal ultrasonography revealed a multilocular cystic lesion to the left of the bladder. Magnetic resonance imaging (MRI) revealed similar findings, with the contents of the cyst showing a low signal on T1-weighted imaging and a high signal on T2-weighted imaging. The patient was referred to our institution for further examination. Enhanced computed tomography (CT) showed a multilocular cystic lesion sized 56 × 44 × 30 mm with partial calcification. The left ovarian vein was dilated, suggesting the origin of the tumor to be the left ovary. Extirpation of the lesion was performed under laparoscopic assistance. Pathological findings indicated an ovarian endometrioma. To our knowledge, this is the youngest report of an OE diagnosed in a patient prior to menstruation.

CONCLUSIONS

OEs in children before menstruation are extremely rare; thus, the long-term prognosis is yet to be determined.

Comparison of ovarian reserve after cystectomy of ovarian endometrioma by bipolar coagulation, suture method, or hemostatic sealants: An updated meta-analysis

AIM

The purpose of the study was to compare the ovarian reserve after cystectomy of ovarian endometrioma by bipolar coagulation, suture method, or hemostatic sealants (HSs).

METHODS

We performed a meta-analysis of studies in which post-cystectomy serum anti-Müllerian hormone (AMH) values were compared between bipolar coagulation and suture method or between bipolar coagulation and HSs. Through a literature search, we retrieved 14 articles which met inclusion criteria and were eligible for final analysis. The articles included 10 randomized trials, 3 prospective studies, and 1 retrospective study (n = 1435). The primary outcome was post-cystectomy serum AMH values.

RESULTS

Both bipolar coagulation and suture methods showed significantly lower post-cystectomy AMH values at 3, 6, and 12 months. However, post-cystectomy serum AMH values at 12 months were significantly higher in the suture method group compared to the bipolar coagulation (weighted mean difference [WMD]: -1.10, 95% confidence interval [CI]: -1.83, -0.38, p = 0.003, I2 = 89, n = 3). The suture method also showed a lower decline rate at 3 months post-cystectomy compared to the bipolar coagulation group (WMD: -25.13%, 95% CI: -49.56 to -0.70, p = 0.04, I2 = 95%, n = 2). Overall, pregnancy rates were similar between the two groups. Between the bipolar coagulation and HSs group, serum AMH values at 3 months post-cystectomy were similar (WMD: -0.46, 95% CI: -1.04 to 0.13, p = 0.13, I2 = 0%, n = 3). However, the HSs group showed a less decline rate at 3 months post-cystectomy compared to the bipolar coagulation group (WMD: -17.02%, 95% CI: -22.81, -11.23, p < 0.00001, I2 = 0%, n = 3).

CONCLUSIONS

Both the suture method and HSs may have potential benefits in the preservation of ovarian reserve over the bipolar coagulation method when cystectomy for ovarian endometrioma is performed.

AURKA Enhances the Glycolysis and Development of Ovarian Endometriosis Through ERβ

Ovarian endometriosis (EMs) is a benign, estrogen-dependent gynecological disorder. Estrogen receptor beta (ERβ), a nuclear receptor for estradiol, plays an important role in the development of ovarian EMs. Here, we investigated the biological significance of aurora kinase A (AURKA) in ovarian EMs and the mechanism by which it regulates ERβ. We used immunohistochemical assays to verify that AURKA and ERβ were highly expressed in ectopic endometrial tissues. Cell proliferation and colony formation assays were used to demonstrate that AURKA promoted the proliferation of EMs cells. Wound-healing assay, Transwell migration assay, and Matrigel invasion assay further showed that AURKA enhanced the ability of EMs cells to migrate and invade. In addition, AURKA was shown to stimulate glycolysis in EMs cells by measuring the concentration of glucose and lactate in the cell supernatants. Moreover, the AURKA inhibitor alisertib was found to inhibit the progression of ovarian EMs and glycolysis in a mouse model of EMs by measuring ectopic tissues as well as by testing the peritoneal fluid of mice. Furthermore, coimmunoprecipitation assay showed that AURKA interacted with ERβ. The rescue experiments confirmed that AURKA regulated the development and glycolysis of ovarian EMs in an ERβ-dependent manner. AURKA contributed to the development of ovarian EMs by upregulating of ERβ. AURKA may represent a new target for the treatment of ovarian EMs.

Effect of hormonal treatment on evolution of endometriomas: An observational study

OBJECTIVE

To evaluate the evolution of endometriomas with or without medical treatment.

METHODS

This retrospective observational study was performed at the Gynaecological Center, Hôpital La Conception (Assistance Publique Hopitaux de Marseille). We reviewed clinical data of patients with at least one endometrioma diagnosed by magnetic resonance imaging (MRI) and at least one other MRI exam after more than three months. Patients were divided into groups receiving medical treatment and without medical treatment (high-dose progestins, low-dose progestins or combined contraceptives). The primary objective was to evaluate the evolution of endometriomas with or without hormonal treatment. The primary evaluation criterion was the diameter of the endometriomas, and the secondary evaluation criterion was the number of endometriomas for each patient observed. The secondary objective was to evaluate whether different categories of hormonal treatment have different efficacity in the evolution of endometriomas.

RESULTS

We included 68 patients, 39 (57,4%) with hormonal treatment and 29 (42,6%) without hormonal treatment. There were 105 total endometriomas identified at the first MRI, 52 in patients with hormonal treatment and 53 in patients without treatment. The mean diameter of the endometriomas in patients with hormonal treatment was 31,48 ± 18,1 mm at the first MRI and 23,60 ± 15,3 mm at the second MRI. The mean diameter of the endometriomas in patients without treatment was 33,57 ± 19,7 mm at the first MRI and 40,11 ± 25,7 mm at the second MRI (statistically significant difference, p = 0.01). The mean number of endometriomas in patients with treatment was 1,79 ± 1,1 at the first MRI and 1,18 ± 0,9 at the second MRI, while the mean number of endometriomas in patients without hormonal treatment was 1,38 ± 0,6 at the first MRI and 1,97 ± 1,5 at the second MRI (difference not statistically significant, p = 0.38). The subgroup analysis differentiated by category of hormonal treatment did not show statistically significant results.

CONCLUSIONS

The present study shows that there is a positive effect of hormonal treatment on reducing the diameter of endometriomas and also a significative increase in endometrioma size in the absence of treatment. There is no evidence of an advantage of a single category of hormonal treatment on this effect on endometriomas. Thus, any medical treatment could be proposed as a first-line therapy for endometriomas that would reduce the size of the endometrioma and thereby help to avoid surgical intervention.

Analysis of cumulative live birth rate outcomes of three ovarian stimulation protocols in patients after laparoscopic cystectomy of ovarial endometrioma: a retrospective cohort study

BACKGROUND

Previous studies have reported that after laparoscopic cystectomy of ovarial endometrioma, the ovarian response to gonadotropin (Gn) significantly decreased. However, for patients with diminished ovarian reserve (DOR) after ovarian surgery, how to choose the most appropriate controlled ovarian hyperstimulation protocol has not been concluded. Compared with the traditional agonist regimen, the gonadotropin (Gn)-releasing hormone (GnRH) antagonist, microstimulation, and progestin-primed ovarian stimulation (PPOS) protocols are simple to operate and have a shorter cycle, which are often used in patients with DOR. So the purpose of our study is to compare the assisted reproductive outcomes of these three controlled ovarian hyperstimulation protocols in patients with DOR following laparoscopic cystectomy of ovarial endometrioma.

METHODS

In this retrospective cohort study, 89 patients with DOR who had undergone in vitro fertilisation/intracytoplasmic sperm injection at the Department of Reproductive Medicine at the Third Affiliated Hospital of Zhengzhou University from 1 to 2018 to 31 December 2020 were included. According to the controlled ovarian hyperstimulation protocols employed, the patients were divided into GnRH antagonist (38 patients), PPOS (27 patients), and microstimulation (24 patients) groups. The basic data and clinical outcomes of the three groups were compared. The main outcome measure was the cumulative live birth rate.

RESULTS

No significant differences in the age of the female patients and their spouses and female patients' body mass index and basal endocrine levels (follicle-stimulating hormone and oestradiol) were noted among the three groups (P > 0.05). The GnRH antagonist group had higher antral follicle counts, greater endometrial thickness on the human chorionic Gn injection day, greater number of oocytes retrieved, and higher two pronuclear embryo counts than did the other two groups. However, the starting dosage of Gn was lower in the GnRH antagonist group than in the other two groups. The microstimulation group had a significantly higher oocyte output rate and high-quality embryo rate than did the other two groups (P < 0.05). No significant differences in the total dosage of Gn, cumulative pregnancy rate, cumulative live birth rate, viable embryo rate, and blastocyst formation rate were observed among the three groups (P > 0.05).

CONCLUSION

In conclusion, for patients aged under 40 years who experienced DOR after laparoscopic cystectomy of ovarial endometrioma, GnRH antagonist protocol and PPOS protocol can obtain better ovulation induction outcomes and cumulative live birth rate than microstimulation protocol, and are more suitable ovulation induction protocols.

Surgical Management of Ovarian Endometrioma: Impact on Ovarian Reserve Parameters and Reproductive Outcomes

Ovarian endometriomas have a negative impact on a patient's reproductive potential and are likely to cause a reduction in ovarian reserve. The most commonly employed ovarian reserve parameters are anti-Müllerian hormone (AMH) and antral follicular count (AFC). Surgical management options of endometrioma include cystectomy, ablative methods, ethanol sclerotherapy and combined techniques. The optimal surgical approach remains a matter of debate. Our review aimed to summarize the literature on the impact of surgical management of endometrioma on AMH, AFC and fertility outcomes. Cystectomy may reduce recurrence rates and increase chances of spontaneous conception. However, a postoperative reduction in AMH is to be anticipated, despite there being evidence of recovery during follow-up. The reduction in ovarian reserve is likely multi-factorial. Cystectomy does not appear to significantly reduce, and may even increase, AFC. Ablative methods achieve an ovarian-tissue-sparing effect, and improved ovarian reserve, compared to cystectomy, has been demonstrated. A single study reported on AMH and AFC post sclerotherapy, and both were significantly reduced. AMH levels may be useful in predicting the chances of conception postoperatively. None of the aforementioned approaches has a clearly demonstrated superiority in terms of overall chances of conception. Surgical management of endometrioma may, overall, improve the probability of pregnancy. Evidence on its value before medically assisted reproduction (MAR) is conflicting; however, a combination of surgery followed by MAR may achieve the optimal fertility outcome. In view of the complexity of available evidence, individualization of care, combined with optimal surgical technique, is highly recommended.

The Impact of Endometrioma on Embryo Quality in In Vitro Fertilization: A Retrospective Cohort Study

The influence of endometrioma on oocyte and embryo competence is inconclusive. Furthermore, the benefits of surgical treatment remain uncertain. This study aimed to investigate the effect of endometrioma on oocyte and embryo quality from a morphological perspective and further explore whether surgery could contribute to improving oocyte and embryo competence. A total of 664 IVF cycles with endometrioma (538 cycles underwent surgeries) and 3133 IVF cycles from the control group were included. The propensity score matching was used to balance the baseline differences between groups. There was a lower MII oocyte rate (85.0% versus 87.8%, p < 0.001; 84.9% versus 87.6%, p = 0.001) and a similar good-quality embryos rate in women with endometrioma (and those who underwent surgeries) compared with control group. For women with endometrioma, the rates of blastocyst development (67.1% versus 60.2%; p = 0.013) and good blastocyst development (40.7% versus 35.2%; p = 0.049) were significantly higher in those who had undergone surgical treatment compared with those who had not, but the rates of MII oocytes (79.9% versus 87.7%; p < 0.001) and normal fertilization (55.2% versus 66.2%; p < 0.001) were lower. The study indicates that endometrioma, including its surgical treatment, compromises the oocyte maturity not the embryo quality at the cleavage stage; however, the surgery seems to contribute to improving blastocyst development.

The Expression of TGF-β1, SMAD3, ILK and miRNA-21 in the Ectopic and Eutopic Endometrium of Women with Endometriosis

The molecular pathogenesis of endometriosis has been associated with pathological alterations of protein expression via disturbances in homeostatic genes, miRNA expression profiles, and signaling pathways that play an essential role in the epithelial-mesenchymal transition (EMT) process. TGF-β1 has been hypothesized to play a key role in the development and progression of endometriosis, but the activation of a specific mechanism via the TGF-β-SMAD-ILK axis in the formation of endometriotic lesions is poorly understood. The aim of this study was to assess the expression of EMT markers (TGF-β1, SMAD3, ILK) and miR-21 in ectopic endometrium (ECE), in its eutopic (EUE) counterpart, and in the endometrium of healthy women. The expression level of the tested genes and miRNA was also evaluated in peripheral blood mononuclear cells (PBMC) in women with and without endometriosis. Fifty-four patients (n = 54; with endometriosis, n = 29, and without endometriosis, n = 25) were enrolled in the study. The expression levels (RQ) of the studied genes and miRNA were evaluated using qPCR. Endometriosis patients manifested higher TGF-β1, SMAD3, and ILK expression levels in the eutopic endometrium and a decreased expression level in the ectopic lesions in relation to control tissue. Compared to the endometrium of healthy participants, miR-21 expression levels did not change in the eutopic endometrium of women with endometriosis, but the RQ was higher in their endometrial implants. In PBMC, negative correlations were found between the expression level of miR-21 and the studied genes, with the strongest statistically significant correlation observed between miR-21 and TGF-β1. Our results suggest the loss of the endometrial epithelial phenotype defined by the differential expression of the TGF-β1, SMAD3 and ILK genes in the eutopic and ectopic endometrium. We concluded that the TGF-β1-SMAD3-ILK signaling pathway, probably via a mechanism related to the EMT, may be important in the pathogenesis of endometriosis. We also identified miR-21 as a possible inhibitor of this TGF-β1-SMAD3-ILK axis.

CHIP induces ubiquitination and degradation of HMGB1 to regulate glycolysis in ovarian endometriosis

Ovarian endometriosis is a common gynecological condition that can cause infertility in women of childbearing age. However, the pathogenesis is still unknown. We demonstrate that the carboxyl terminus of Hsc70-interacting protein (CHIP) is a negative regulator in the development of endometriosis and reduces HMGB1 expression in endometriotic cells. Meanwhile, CHIP interacts with HMGB1 and promotes its ubiquitinated degradation, thereby inhibiting aerobic glycolysis and the progression of endometriosis. Furthermore, the CHIP agonist YL-109 effectively suppresses the growth of ectopic endometrium in endometriosis mouse model, which could be a potential therapeutic approach for endometriosis. In conclusion, our data suggest that CHIP may inhibit the development of endometriosis by suppressing the HMGB1-related glycolysis.

Activin A Modulates Betaglycan Shedding via the ALK4-SMAD3-Dependent Pathway in Endometriotic Cells

The TGF-β superfamily members, activins and inhibins, are mainly involved in cell proliferation, cell survival, invasion, immune surveillance, and lesion growth in endometriosis. Herein, we investigated the modulation of the TGF-β type III receptor (betaglycan or BG) by activin A and inhibin A in endometriosis in vitro. Often, BG undergoes ectodomain shedding releasing soluble BG (sBG) which frequently antagonizes TGF-β signaling. The effects of activin A on BG shedding and signaling pathways involved were evaluated with the inhibitors LY364947 and SIS3, siRNA knockdown in human endometrial cells (12Z, THESC, Ishikawa, and primary stromal cells) and were quantified with BG ELISAs. The effects of activin A and inhibin A on the secretion of MMP2 and MMP3 were analyzed using ELISAs. The effects of activin A on the BG expression were analyzed using RT-qPCR and western blot. The CCK-8 and BrdU assays were used to evaluate the effects of the recombinant BG on cell viability and proliferation. Activin A stimulation resulted in a significant time- and dose-dependent reduction in BG shedding, which was found to be activin A/ALK-4/SMAD3- but not SMAD2-dependent. Activin A increased the BG mRNA expression but had no effect on the protein expression. Likewise, inhibin A was found to block BG shedding. Activin A, but not inhibin A, significantly enhanced the secretion of MMP2 and MMP3. The recombinant BG had no effect on the viability and proliferation of endometriotic cells. Together, these observations support a novel role for activin A with BG in modulating the TGF-β superfamily ligands in endometrial cells in vitro.

Transvaginal Ultrasound in the Diagnosis and Assessment of Endometriosis-An Overview: How, Why, and When

Endometriosis is a common gynaecological disease, causing symptoms such as pelvic pain and infertility. Accurate diagnosis and assessment are often challenging. Transvaginal ultrasound (TVS), along with magnetic resonance imaging (MRI), are the most common imaging modalities. In this narrative review, we present the evidence behind the role of TVS in the diagnosis and assessment of endometriosis. We recognize three forms of endometriosis: Ovarian endometriomas (OMAs) can be adequately assessed by transvaginal ultrasound. Superficial peritoneal endometriosis (SUP) is challenging to diagnose by either imaging modality. TVS, in the hands of appropriately trained clinicians, appears to be non-inferior to MRI in the diagnosis and assessment of deep infiltrating endometriosis (DIE). The IDEA consensus standardized the terminology and offered a structured approach in the assessment of endometriosis by ultrasound. TVS can be used in the non-invasive staging of endometriosis using the available classification systems (rASRM, #ENZIAN). Given its satisfactory overall diagnostic accuracy, wide availability, and low cost, it should be considered as the first-line imaging modality in the diagnosis and assessment of endometriosis. Modifications to the original ultrasound technique can be employed on a case-by-case basis. Improved training and future advances in ultrasound technology are likely to further increase its diagnostic performance.

A Case of Ruptured Decidualized Ovarian Endometrioma: Usefulness of Serial MRI for Determining Adequate Management

Decidualization can originate in ovarian endometrioma by elevated serum progesterone levels during pregnancy, which mimics malignancy on ultrasonography. Moreover, decidualized ovarian endometrioma may rupture and cause acute abdominal pain during pregnancy. Magnetic resonance imaging (MRI) is reportedly useful in differentiating decidualized ovarian endometriomas from malignancies. However, to our knowledge, serial MRI of decidualized ovarian endometrioma before and after rupture has not been reported. Herein, we report the case of a 39-year-old woman with a ruptured decidualized ovarian endometrioma in which serial MRI was useful for adequate management. She had a history of right ovarian endometrioma. Transvaginal ultrasonography at 20 weeks of gestation showed the known right ovarian endometrioma with mural nodules that were not evident before pregnancy. MRI for further evaluation showed ovarian endometrioma with mural nodules with signals similar to those of the placenta. Based on the MRI findings, we diagnosed a decidualized ovarian endometrioma. At 27 weeks of gestation, she complained of sudden abdominal pain, for which MRI was performed. MRI showed disappearance of the ovarian endometrioma and bloody ascites, based on which we diagnosed a ruptured ovarian endometrioma. The abdominal pain subsided immediately, and a conservative observational treatment approach was taken. At 37 weeks of gestation, right ovarian cystectomy was performed simultaneously with an elective cesarean section, which revealed a ruptured decidualized ovarian endometrioma. Our findings demonstrate that the accurate diagnosis of a ruptured decidualized ovarian endometrioma on serial MRI can contribute to its management.

Measuring intraobserver and intermethod reliability of endometriotic cyst volumes: A comparison between MRI and 3D transvaginal ultrasound in endometriosis

Objectives:

To identify the intraobserver and intermethod reliability of three-dimensional transvaginal ultrasound (3D-TVUS) using the software VOCAL and XI VOCAL compared with magnetic resonance imaging (MRI) for volumetric measurement of ovarian endometrioma.

Methods:

The intermethod and intraobserver reliability of endometrioma volumes were assessed in 16 women diagnosed with endometriosis through laparoscopy with histologic confirmation and presenting with uni- or bilateral endometriomas. In total, volumes of 23 endometriomas were assessed with two-dimensional and three-dimensional transvaginal ultrasound and 6 mm magnetic resonance imaging. Examinations took place at two moments in one menstrual cycle: day 2–4 (T0) and day 20–22 (T1).

Results:

The intraclass correlation for intraobserver reliability is good to very good for all three techniques ranging from the lowest value of 0.953 to the highest of 1.000. MRI has the most narrow limits of agreement (−3.93 to 4.53), followed by XI VOCAL (−5.16 to 5.65) while VOCAL has the widest limits of agreement (−10.22 to 11.39). Intraclass correlations are poor in the comparison of XI VOCAL to MRI, moderate between VOCAL and XI VOCAL, and good for the comparison between VOCAL and MRI. Limits of agreement vary per technique. When comparing 3D imaging techniques with 2D TVUS, XI VOCAL versus 2D TVUS provide the smallest limits of agreement.

Conclusions:

MRI and XI VOCAL provide the best intraobserver reliability. The different imaging techniques are not interchangeable. As TVUS is a more readily available and cost-efficient imaging technique the usage of XI VOCAL is advised.

Assisted reproductive treatment outcomes of women with endometriomas: Either with or without previous ovarian surgery

OBJECTIVE

The present study aimed to evaluate and compare the assisted reproductive technique (ART) outcomes of women with endometriomas either with or without prior endometrioma surgery.

MATERIALS AND METHODS

A total of 122 women with endometriomas underwent intracytoplasmic sperm injection-embryo transfer (ICSI-ET) at a tertiary IVF Center, between 2014 and 2019, were included in this retrospective study. Of this group, 38 patients had recurrent endometriomas and 84 patients had primary endometrioma without a previous endometrioma surgery. The outcomes of ART treatment including cancellation rates before ET, numbers of oocytes obtained, implantation, clinical pregnancy and live birth rates were compared between the groups. A logistic regression model including potential confounders as age and presence of male factor infertility was used to evaluate the possible effect of recurrent endometriomas on the live birth.

RESULTS

The baseline characteristics of the groups were similar. The poor ovarian response rate, defined as the harvest of fewer than four oocytes, was identified in 35.7% and 42.1% of primary and recurrent endometrioma groups, respectively. The implantation (27.2 ± 42.7% vs 24.1 ± 41.4%, P = .74), clinical pregnancy/ET (30.9% vs 27.6%, P = .93 ) and live birth rates/ET (22.1% vs 17.2%, P = .79) CONCLUSION: The ART outcomes of patients with primary and recurrent endometriomas do not seem different in terms of response to ovarian stimulation and live birth rates after ICSI. These results may indicate that the recurrence of the endometrioma might not have a further detrimental effect on ART outcome than the disease itself.

Clinical Features and Long-Term Outcomes After Laparoscopic Surgery in Patients Co-existing With Endometriosis and Adenomyosis

Objective: To investigate the difference of clinical features and outcomes between EM patients with and without AM after following up for at least 6 years after surgery.

Methods: We retrospectively analyzed 358 EM patients who had a minimum of 6 years follow-up after laparoscopic cystectomy, which was performed by one single doctor at Peking Union Medical College Hospital from January 2009 to April 2013. All women were divided into AM group and non-AM group and analysis was performed in preoperative characteristics, surgical findings and postoperative outcomes during follow-up.

Results: A total of 358 EM patients were recruited, of which 142 (39.7%) were in the AM group and the rest 216 (60.3%) in the non-AM group. Between the two group, the mean age was 34.6 vs. 32.2 years (P < 0.001). The mean operating time in the AM and non-AM group was 73.2 vs. 61.9 min (P < 0.001). According to the revised AFS classification, the mean score of the two group were 60.3 vs. 45.5 (P < 0.001). At the end of the follow-up, though the AM group was with higher rate of disease relapse, yet no significant difference was found between the two groups in statistical comparison (34/142 [23.9%] vs. 34/216 [15.7%], P = 0.053). With a minimum follow-up of 6 years after laparoscopic cystectomy, failed and successful pregnancy were seen in 107/142(75.4%) and 35/142 (24.6%) patients in the AM group vs. 114/216(52.8%) and 102/216 (47.2%) patients in the non-AM group (P < 0.05). As for the successfully pregnant patients, live births, including spontaneous pregnancy and IVF-ET, were seen in 34/35 (97.1) vs. 99/102 (97.1) patients between AM and non-AM groups, while others ended in spontaneous abortion. No significant associations were found between the two groups in infertility, leiomyoma presence, the size of ovarian endometrioma, type of deep infiltrating endometriosis (DIE) or type of recurrence (P > 0.05).

Conclusion: Compared with non-AM group, EM patients with concurrent AM may have higher age, longer mean operating time and higher mean AFS score. In terms of fertility outcomes, patients in the AM group were with lower likelihood of pregnancy after surgery during the long-time follow-up.

Assisted reproductive technique outcomes in patients with endometrioma undergoing sclerotherapy vs laparoscopic cystectomy: Prospective cross-sectional study

PURPOSE

The authors compared assisted reproductive technique (ART) outcomes and the recurrence rate of endometrioma in the infertile patients undergoing sclerotherapy vs laparoscopic ovarian cystectomy.

METHODS

In this prospective cross-sectional study, a total of 101 infertile patients, with unilateral endometriomas, were divided into two groups. The first group (n = 57) underwent ART after 1 year of unsuccessful spontaneous pregnancy after laparoscopic ovarian cystectomy; the second group (n = 44) had ethanol sclerotherapy (EST) at the time of oocyte retrieval. The authors measured the number of oocytes, clinical pregnancy rate (CPR), live birth rate (LBR), complication, and recurrence of endometriomas as the primary and secondary outcomes.

RESULTS

The two groups had no significant differences in baseline characteristics and ovarian stimulation markers and also total number of oocytes. 42.1% and 34.1% of the patients (n = 24 and 15) had clinical pregnancy, and 38.6% and 29.5% (n = 22 and 13) had live birth following ART cycles in the surgery group and sclerotherapy group (P = .41, 0.34). The recurrence rates were 14.0% and 34.1% in the surgery and sclerotherapy groups (P = .017, X 2 = 5.67).

CONCLUSIONS

Ethanol sclerotherapy can be a good alternative to surgery concerning the treatment of endometrioma; however, the recurrence of the disease in this group is significantly higher.

The rate of oocytes with granular cytoplasm is higher in women with endometrioma in ICSI cycles

The purpose of this study was to investigate the impact of endometrioma on oocyte morphology and fertility outcome in intracytoplasmic sperm injection (ICSI)cycles. The study material was obtained from 114 ICSI cycles of infertile women aged between 20 and 38 years with ovarian endometriomas and unexplained infertility. In total, 644 mature oocytes were included in the analysis. The rates of specific oocyte morphological abnormalities were similar between the two groups however the central granulation rate was significantly higher in the group with endometrioma (p < .05). Fertilisation rate were not significantly different between the groups (p ≥ .05) however the numbers of metaphase 2 (MII) oocytes and embryos were lower in the endometrioma group (p ≤ .05). Endometrioma was associated with a higher rate of oocytes with granular cytoplasm, despite the fertilisation rate the numbers of the MII oocytes and embryo were affected.IMPACT STATEMENTWhat is already known on this subject? The association between endometrioma and infertility is a well-known condition, but the possible mechanisms of the effects of endometrioma on women's fertility is still debated and controversial. There is limited data on the effect of endometrioma on oocyte morphology. Low oocyte quality and lower fertilisation rates might be the main cause of adverse pregnancy outcomes during in vitro fertilisation/intracytoplasmic sperm injection cycles.What do the results of this study add? Endometrioma was associated with a higher rate of oocytes with granular cytoplasm, and lower metaphase 2 oocytes and embryos.What are the implications of these findings for clinical practice and/or further research? Future studies using further oocyte quality assessment methods and prospective observational studies including live-birth rate should be designed to better understand how endometrioma affects fertility outcomes.

Intricate Connections between the Microbiota and Endometriosis

Imbalances in gut and reproductive tract microbiota composition, known as dysbiosis, disrupt normal immune function, leading to the elevation of proinflammatory cytokines, compromised immunosurveillance and altered immune cell profiles, all of which may contribute to the pathogenesis of endometriosis. Over time, this immune dysregulation can progress into a chronic state of inflammation, creating an environment conducive to increased adhesion and angiogenesis, which may drive the vicious cycle of endometriosis onset and progression. Recent studies have demonstrated both the ability of endometriosis to induce microbiota changes, and the ability of antibiotics to treat endometriosis. Endometriotic microbiotas have been consistently associated with diminished Lactobacillus dominance, as well as the elevated abundance of bacterial vaginosis-related bacteria and other opportunistic pathogens. Possible explanations for the implications of dysbiosis in endometriosis include the Bacterial Contamination Theory and immune activation, cytokine-impaired gut function, altered estrogen metabolism and signaling, and aberrant progenitor and stem-cell homeostasis. Although preliminary, antibiotic and probiotic treatments have demonstrated efficacy in treating endometriosis, and female reproductive tract (FRT) microbiota sampling has successfully predicted disease risk and stage. Future research should aim to characterize the "core" upper FRT microbiota and elucidate mechanisms behind the relationship between the microbiota and endometriosis.

Health-Related Quality of Life in Adult Spanish Women with Endometriomas or Deep Infiltrating Endometriosis: A Case-Control Study

Endometriosis is a disabling disease that may significantly compromise a woman’s social relationships, sexuality, and mental health. Considering the impact of endometriomas and deep infiltrating endometriosis (DIE) on quality of life and the limited number of papers on this topic, the objective of this study was to assess health-related quality of life (HRQoL) in adult Spanish women with the condition. A case-control study was conducted on a group of 99 patients with ovarian endometriomas or DIE and 157 controls. Women underwent physical and gynecological examinations, and they completed health questionnaires including the Short Form-12v2 (SF-12v2), a survey for HRQoL. Eight scales and two component summary scores (Physical (PCS) and Mental (MCS), respectively) were calculated. Women with endometriomas or DIE had significantly worse PCS: 47.7 ± 9.7 vs. 56.1 ± 5.9, respectively (p < 0.001) compared to controls, as well as lower scores on seven out of the eight scales (p < 0.01). No significant differences were found for the MCS. Conclusions: HRQoL was significantly lower in patients with endometriomas or DIE compared to controls. If confirmed, these results may have important implications for prevention, clinical practice, and intervention.

Ovarian reserve and recurrence 1 year post-operatively after using haemostatic sealant and bipolar diathermy for haemostasis during laparoscopic ovarian cystectomy

RESEARCH QUESTION

Is there a difference in the ovarian reserve 1 year post-operatively in those who used a haemostatic sealant or bipolar diathermy for haemostasis during laparoscopic ovarian cystectomy for ovarian endometriomas?

DESIGN

This was an extended follow-up observational study of a previous randomized controlled trial where women aged 18 to 40 years with 3-8 cm unilateral or bilateral endometriomas were randomized to receive haemostasis by a haemostatic sealant or bipolar diathermy following ovarian cystectomy. The primary outcome was the ovarian reserve as assessed by antral follicle count (AFC) 1 year post-operatively. Secondary outcomes included the recurrence rate of ovarian endometrioma, the change in anti-Müllerian hormone (AMH) and FSH concentrations, and reproductive outcomes.

RESULTS

The significant increase in AFC at 3 months after initial surgery (P = 0.025) in the haemostatic sealant group compared with the diathermy group was sustained at 1 year (P = 0.024) but there was no difference in AMH or FSH concentrations between the groups throughout the follow-up period. The recurrence rate in the FloSeal group was 7.7% (n = 3/39) compared with 22.2% (n = 8/36) in the diathermy group (P = 0.060). The recurrence rate in women who had bilateral lesions was significantly higher than those with unilateral lesions (risk ratio 5.33, interquartile range 1.55-18.38). No difference in reproductive outcomes was found between the two groups.

CONCLUSIONS

Applying haemostatic sealant after laparoscopic cystectomy of ovarian endometriomas produces a significantly greater improvement in AFC, which was apparent at 3-month follow-up, and was sustained at 1-year follow-up without compromising the recurrence rate.

Ovarian endometriosis, a precursor of ovarian cancer: Histological aspects, gene expression and microRNA alterations (Review)

Ovarian endometriosis is a frequent chronic gynecological disease with an uncertain evolution regarding its progression or association with ovarian malignant lesions. The present review summarized the histological aspects, gene expression and microRNA (miRNA/miR) alterations associated with ovarian endometriosis and cancer and their possible interaction. The endometriosis-ovarian cancer interaction has been proposed by certain researchers as a single entity. Histological results indicated that endometriosis has been in different circumstances coexisting with ovarian cancer, with reference to endometrioid and clear cell carcinoma. Endometriosis with moderate and severe atypia can influence cell proliferation and architecture, resulting in a possible malignant transformation. Gene expression analysis indicated that the pathologies of both endometriosis and ovarian cancer are characterized by genetic instability from a molecular point of view, as several important genetic mutations, including ARID1A, PI3KCA, PTEN, BRCA1, BRCA2, TP53 and KRAS genes, were identified. miRNA alterations have been implicated in the regulation of gene expression. Common dysregulated miRNAs, such as miR-331, miR-335, miR-891, miR-548, miR-124, miR-148, miR-215, miR-192, miR-337, miR-153, miR-155, miR-144, miR-221 and miR-3688 were extensively investigated in understanding endometriosis and ovarian cancer evolution. From a combined viewpoint including histological aspects, gene expression and miRNA alterations, it is reasonable to speculate that endometriosis is associated with ovarian cancer. Ovarian endometriosis lesions may present a risk for ovarian malignant lesions, which supports a model of endometriosis as a malignant precursor. However, the endometriosis-ovarian cancer association is not widely accepted in the literature and additional studies are required to validate this association.

Postoperative hormonal treatment for prevention of endometrioma recurrence after ovarian cystectomy: a systematic review and network meta-analysis

BACKGROUND

The efficacy of hormonal regimens for the prevention of endometrioma recurrence in women who have undergone conservative surgery is still controversial.

OBJECTIVE

To compare the efficacy of different hormonal regimens in this context and to rank them.

SEARCH STRATEGY

MEDLINE and Scopus databases were searched through January 2020.

SELECTION CRITERIA

Randomised controlled trials (RCTs) or cohorts, comparing the effect of any pair of interventions (i.e. cyclic oral contraceptives [OC], continuous OC, gonadotropin-releasing hormone agonist [GnRHa], dienogest [DNG], levonorgestrel-releasing intrauterine system [LNG-IUS] and expectant management) on endometrioma recurrence were selected.

DATA COLLECTION AND ANALYSIS

Data were independently extracted by two reviewers. Relative treatment effects were estimated using network meta-analysis (NMA) and ranked in descending order.

MAIN RESULTS

Six RCTs (675 patients) and 16 cohorts (3089 patients) were included. NMA of the RCTs involving expectant management, cyclic OC, continuous OC, GnRHa and GnRHa + LNG-IUS, showed that all hormonal regimens had a nonsignificant lower risk of endometrioma recurrence compared with expectant management. NMA of the cohorts involving expectant, cyclic OC, continuous OC, GnRHa, DNG, LNG-IUS, GnRHa + OC, and GnRHa + LNG-IUS indicated that LNG-IUS, DNG, continuous OC, GnRHa + OC and cyclic OC had a significantly lower risk of endometrioma recurrence than expectant management. LNG-IUS was ranked highest, followed by DNG and GnRHa + LNG-IUS. Long-term use of hormonal treatment either OC or progestin had a significantly lower risk of endometrioma recurrence than expectant treatment.

CONCLUSION

In the NMA of RCTs, there was no evidence supporting hormonal treatment for postoperative prevention of endometrioma recurrence. This was at odds with the cohort evidence, which found the protective effect of OC and progestin regimens, especially long-term treatment. Large-scale RCTs of these agents are still required.

TWEETABLE ABSTRACT

Hormonal regimens given as long-term treatment tend to reduce risk of endometrioma recurrence after conservative surgery.

Circulating CD56+ NKG2D+ NK cells and postoperative fertility in ovarian endometrioma

The current biomarkers for postoperative fertility assessment caused by ovarian endometrioma (OE) are insufficient. The present study hypothesized that the peripheral lymphocyte subpopulation can be used as a candidate biomarker of postoperative infertility in OE. The association of the number of circulating CD4/CD8 T, NK, and γδ T cells with postoperative fertility was assessed in 33 OE patients aged 20 ~ 40 years between June 2018 and January 2019. Concomitantly, 68 healthy female subjects were recruited. The changes in the baseline immune characteristics between the two groups were compared. The data demonstrated significant differences in the ratio of CD4/CD8 T cells and the number of CD56+ NKG2D+ NK cells and γδ T cells between OE patients and control subjects. The patients were followed-up till December 2019 and the number of CD56+ NKG2D+ NK cells in the cases was a significant predictor for postoperative fertility as determined by different COX regression models (crude HR = 0.220, 95% CI = 0.059–0.822; adjusted HR = 0.127, 95% CI = 0.024–0.675). A significant delay to successful pregnancy was noted in OE patients (median time, 173 vs. 99 days, log-rank P = 0.013). The present findings suggested that CD56+ NKG2D+ NK cells are a candidate biomarker of postoperative fertility in OE patients. Larger population studies are warranted.

Effect of Dienogest therapy on the size of the endometrioma

Studies have been published on the efficacy of Dienogest in the management of pain symptoms in endometriosis. Nonetheless, few data are available on the reducing effect on endometrioma's size. The aim of the study was to evaluate if Dienogest could determine significant changes in size, as well as in symptoms. In this prospective observational study, patients were enrolled with pain symptoms and at least one endometrioma diagnosed via TV-US. The volume of the endometrioma and pain symptoms was measured according to the LxDxWx0.5233 formula and VAS, respectively. Dienogest 2 mg was administered daily. Follow-up visits were scheduled after 6 and 12 months of treatment to assess changes in patients' symptoms and endometrioma's volume. Seventy patients were enrolled, 63 patients completed a 6-month treatment. The reduction of the mean volume after 6 months was 66.71%. Fifty-eight patients completed the 12 month-treatment. The reduction of the mean volume after 12 months was 76.19%. Dysmenorrhea showed a 74.05% reduction after 6 months and a 96.55% reduction after 12 months. Patients reported a reduction in dyspareunia and chronic pelvic pain of 42.71% and 48.91% after 6 months and 51.93% and 59.96% after 12 months, respectively. Dienogest leads to a statistically significant reduction of endometrioma's volume and pain symptoms.

IL6, IL8, and IL10 in the distinction of malignant ovarian neoplasms and endometriomas

PROBLEM

Studies have shown a relationship between endometriosis and ovarian cancer. Our aims were to evaluate and compare the dosages of cytokines IL-2, IL-5, IL-6, IL-8, IL-10, and TNF-α in serum, intracystic fluid, and peritoneal fluid of patients with ovarian endometrioma, malignant and benign ovarian neoplasms, and non-neoplastic ovarian tumors; to verify if there is a correlation between the values of these cytokines between ovarian endometrioma and ovarian malignancy; and to determine the best cut-off point for serum cytokines that can be used to differentiate patients with ovarian malignancy and endometrioma.

METHOD OF STUDY

The concentrations of cytokines were quantified by enzyme-linked immunosorbent assay (ELISA), analyzed by Kruskal-Wallis test with the Dunn post-test. Receiver operating feature (ROC) curve was used to obtain the area under the curve (AUC) and to determine the best cut-off values that could be used in the diagnosis of ovarian malignancy. Correlations of cytokine concentrations were performed by the Spearman test.

RESULTS

IL-6, IL-8, and IL-10 concentrations were higher in patients with malignant neoplasia. When evaluating the area under the curve (AUC) of serum cytokine levels comparing patients with malignant neoplasia and endometriomas, there was statistical significance for IL-6, IL-8, and IL-10.

CONCLUSION

Our results showed utility in serum concentrations of IL-6, IL-10, and IL-8 as parameters that differentiate endometriomas from ovarian malignancies.

Feasibility of Laparoscopic Hysterectomy in Stage IV Pelvic Endometriosis: Our Technique and Outcomes

Context:

The definitive surgical treatment of severe endometriosis remains to be hysterectomy whether done by laparoscopy or laparotomy.

Aim:

The aim of this study was to assess the feasibility and outcome of laparoscopic hysterectomy in severe pelvic endometriosis.

Settings and Design:

This retrospective study was carried out in a tertiary center over a period of 5 years (January 2013–December 2017).

Subjects and Methods:

A total of 70 patients who underwent laparoscopic hysterectomy for severe pelvic endometriosis with a score of more than 40, which was defined by the revised American Fertility Society classification, were included in the study. Feasibility of laparoscopic hysterectomy and other clinical parameters such as operative time, blood loss, recurrence of the disease, and need for postoperative medical treatment was analyzed.

Results:

The mean age of the patients was 43.2 ± 4.56. Majority of the women (62.8%) had dysmenorrhea as the primary complaint, followed by menorrhagia (21.4%). Intraoperatively rectovaginal septum was involved in 95% of the cases with complete obliteration of the pouch of Douglas in 80% of the cases. The ureter was involved in 34% of the cases. The bladder was densely adherent in 71.4% of the patients. There was no conversion to laparotomy in any of these patients and no visceral injuries. The mean duration of surgery was 3 h. The estimated blood loss ranged from 100 to 500 ml. The duration of hospital stay was 2–5 days. There was no recurrence during follow-up in any of these patients.

Conclusions:

Laparoscopy in experienced hands is feasible and safe even in difficult cases of Stage IV pelvic endometriosis apart from offering superior results.

Endometrioma surgery is associated with increased risk of subsequent assisted reproductive technology cycle cancellation; a retrospective cohort study

The aim of this study was to assess the effect of laparoscopic removal of endometrioma on assisted reproductive technology (ART) outcome. A retrospective cohort study was conducted at a university hospital between January 2014 and December 2017. The ART group consisted of 26 women who underwent 44 ART cycles in the presence of ovarian endometrioma and the surgery group consisted of 53 women who underwent 58 ART cycles after laparoscopic removal of ovarian endometrioma/s. There were no statistically significant differences between the groups regarding demographic parameters and background features including cycle parameters. The live birth rates in the ART and Surgery groups per embryo transfer were 23.7 and 26.1%, respectively (p  =  .800). The rate of cycle cancellation due to poor response and/or failed oocyte retrieval was significantly higher in the Surgery group than ART group (13.7 vs. 0%, respectively; p = .018). In conclusion, cystectomy significantly increases the risk of cycle cancellation due to poor ovarian response, which might be catastrophic individually. However, it does not seem to affect the live birth rates.IMPACT STATEMENTWhat is already known on this subject? Both the presence of an endometrioma or surgical removal may have deleterious effects on fertility potential.What do the results of this study add? Our results confirm that although cystectomy has no benefit on the number of oocytes collected and live birth rate, it increases the risk of cycle cancellation significantly in assisted reproductive technology cycles following endometrioma surgery.What are the implications of these findings for clinical practice and/or further research? Postponing cystectomy until a freeze-all cycle may be the best option to maximise the number of oocytes retrieved and to maximise the ovarian response.

Fertility Outcomes After Laparoscopic Cystectomy in Infertile Patients with Stage III-IV Endometriosis: a Cohort with 6-10 years of Follow-up

INTRODUCTION

Ovarian endometriosis is the most common type of endometriosis (EM), affecting more than 40% of women with EM. Currently, surgical intervention is still controversial in infertile patients with ovarian endometriosis, especially in those with stage III-IV EM. Very few studies have been done to analyze long-term pregnancy results in patients with endometrioma more than 5 years after surgery. Therefore, the aim of this study was to explore the pregnancy outcomes and the related factors in patients with endometrioma and stage III-IV endometriosis during a long-term follow-up postoperatively.

METHODS

We collected 347 patients with ovarian endometriosis, which included 59 infertile patients with stage III-IV endometriosis who had a minimum of 5 years of postoperative follow-up after undergoing laparoscopic excision of ovarian endometriomas performed by a single doctor at the Peking Union Medical College Hospital from January 2009 to April 2013.

RESULTS

A total of 59 infertile patients were recruited. The mean age was 31.8 ± 3.6 years. The mean size of the endometriomas was 6.8 ± 3.3 cm. Before surgery, dysmenorrhea was present in 88.1% (52/59) of the cases, while chronic pelvic pain was reported in nine cases (15.3%). A total of 20.3% (12/59) of cases were concurrent with leiomyoma, 52.5% (31/59) with deep infiltrating endometriosis (DIE), and 39.0% (23/59) with adenomyosis. During laparoscopy, 21 cases were diagnosed as stage III (35.6%) and 38 as stage IV (64.4%) EM according to the revised American Fertility Society (AFS) classification. After laparoscopic cystectomy, 38 (64.4%) patients became successfully pregnant by the 5th year. All the patients were divided into two groups according to the postoperative pregnancy outcomes. In univariate analysis, the higher mean age and concurrent diagnosis of adenomyosis were seen to be related to poor postoperative pregnancy outcomes (p < 0.05). In multivariate analysis, however, the mean age, chronic pelvic pain (CPP), and adenomyosis were independent risk factors of pregnancy outcomes between the two groups (p < 0.05). With a minimum follow-up of 6 years, 23.7% (14/59) of recurrence was observed in the entire study cohort.

CONCLUSION

Infertile patients with endometrioma and stage III-IV EM may have lower pregnancy rates after laparoscopic cystectomy if they are older and present with CPP and adenomyosis. Our data showed a lower rate of recurrence but a higher rate of pregnancy after surgery.

Live birth rate comparison of three controlled ovarian stimulation protocols for in vitro fertilization-embryo transfer in patients with diminished ovarian reserve after endometrioma cystectomy: a retrospective study

Background

Women with endometriosis and previous cystectomy may respond less well to gonadotropin stimulation, which results in fewer oocytes retrieved and poor pregnancy outcomes. Choosing an appropriate protocol for such populations is essential. This study involved an analysis of the effect of different controlled ovarian stimulation (COS) protocols on the clinical outcomes of in vitro fertilization-embryo transfer (IVF-ET) in women with diminished ovarian reserve (DOR) who underwent ovarian endometrioma cystectomy.

Methods

A total of 342 patients that underwent IVF-ET treatment at the Beijing Obstetrics and Gynecology Hospital from January 1, 2013 to April 30, 2018 were included in this retrospective study. The patients were distributed into three groups according to the COS protocols, namely prolonged GnRH-agonist (Group A, n = 113), GnRH-antagonist (Group B, n = 121), and long GnRH-agonist (Group C, n = 108). The clinical and laboratory parameters of the three protocols were analyzed and a logistic regression of clinical pregnancy and live births was conducted.

Results

There were no significant differences in the age, infertility duration, basic follicle stimulation hormone (FSH), luteinizing hormone (LH), or estradiol (E₂) levels as well as other baseline characteristics among groups (P > 0.05). The total gonadotrophin (Gn) dosage and duration tended to be less in the GnRH-antagonist group than in the others (P < 0.05). No significant differences were found in the implantation rate and clinical pregnancy rate among the groups, but the prolonged GnRH-agonist group showed the highest rates. In addition, no significant differences were present in the number of retrieved oocytes, oocyte fertilization rate, embryo utilization rate, live birth rate, abortion rate, ectopic pregnancy rate, or multiple pregnancy rate in the three groups (P > 0.05). Age had a significant effect on both clinical pregnancy and live birth.

Conclusion

For those DOR patients who had undergone ovarian endometriosis cystectomy, the prolonged GnRH-agonist protocol may achieve better clinical IVF-ET outcomes, but there were no significant differences from the other groups. The GnRH-antagonist protocol may reduce the cost and time of drug treatment. Age should be considered for its influence on pregnancy outcome. However, a larger sample size may be needed for further study.

Oocyte cryopreservation for fertility preservation in women with ovarian endometriosis

RESEARCH-QUESTION

What is the clinical usefulness of oocyte cryopreservation for fertility preservation in women with ovarian endometriosis?

DESIGN

Clinical characteristics were retrospectively analysed in 34 women with endometrioma before a planned ovarian cystectomy. Ovarian stimulation outcomes were compared according to laterality. A one-to-one propensity score-matched analysis was conducted to compare ovarian stimulation outcomes of the first cycle in patients with endometrioma undergoing fertility preservation with those in infertile patients without endometrioma who underwent IVF treatment. The number of oocytes cryopreserved in repeated ovarian stimulation cycles was analysed.

RESULTS

The mean endometrioma size at diagnosis was 6.0 ± 2.5 cm. The mean age, serum anti-Mullerian hormone levels and number of oocytes cryopreserved were 30.7 ± 5.9 years, 1.85 ± 1.14 ng/ml, and 4.8 ± 3.2, respectively. The number of oocytes cryopreserved in bilateral endometrioma compared with unilateral endometrioma patients was 4.1 ± 2.9 versus 5.7 ± 3.4 (P = 0.600). In the propensity score-matched cohort (n = 22 per group), the number of oocytes retrieved was significantly lower in the patients with endometrioma undergoing fertility preservation compared with that in infertile patients without endometrioma (5.4 ± 3.8 versus 8.1 ± 4.8; P = 0.045). A total of 13 (38.2%) patients with endometrioma underwent repeated stimulation. The median (interquartile range) number of cryopreserved oocytes at the first and the second cycle were 3.0 (2.5-6.0) and 5.0 (2.5-7.5), respectively.

CONCLUSIONS

Women with endometrioma should be counselled about oocyte cryopreservation for fertility preservation before surgery. The number of cryopreserved oocytes can be increased by repeated oocyte retrieval.

Evaluation of the ocular surface by impression cytology in patients with endometriosis

OBJECTIVE

The aim of this study was to investigate the effect of endometriosis on the ocular surface.

METHODS

A total of 50 patients were included in the study and divided into two groups. Group 1 consisted of 25 patients with endometriosis. Group 2 had 25 control patients. All patients underwent complete ophthalmic examination, and the right eyes were included in the study. To evaluate the ocular surface, both groups were tested with the following: the Schirmer I test, tear breakup time (TBUT), the conjunctival impression cytology (CIC), and the Ocular Surface Disease Index (OSDI). The results were subsequently compared.

RESULTS

The average Schirmer I test results were 8.40 ± 2.74 mm in group 1 and were significantly lower in patients with endometriosis (P < 0.001). The average TBUT test results were 9.04 ± 3.61 s in group 1 and were significantly lower in patients with endometriosis (P < 0.001). The average OSDI results were 24.04 ± 9.29 in group 1 and were significantly higher in patients with endometriosis (P < 0.001). The average CIC results were 1.76 ± 0.88 in group 1 and were significantly higher in patients with endometriosis (P < 0.001).

CONCLUSIONS

Ocular surface changes, including squamous metaplasia, may be observed in the conjunctiva of patients with endometriosis.

Factors associated with deep infiltrating endometriosis versus ovarian endometrioma in China: a subgroup analysis from the FEELING study

BACKGROUND

To compare potential factors associated with deep infiltrating endometriosis (DIE) versus ovarian endometrioma (OMA) among endometriosis patients in China.

METHODS

A subgroup analysis of factors associated with DIE versus OMA was performed in Chinese women from the FEELING study. This study included 156 OMA patients and 78 DIE patients. Retrospective information on symptoms and previous medical history was collected via face-to-face interviews; patients also completed a questionnaire to provide information on current habits. Univariate and multivariate logistic regression analyses were conducted to identify potential factors that are associated with DIE versus OMA.

RESULTS

From univariate analysis, women who were married, at older age, had any siblings, prior pregnancy, or longer time since age at menarche on the day of visit were more likely to be diagnosed with DIE (P < 0.05). Also, the incidence of previous uterine surgery, menstrual and ovulatory disorders, deep dyspareunia, and gastrointestinal symptoms during menstruation were major factors that were significantly associated with the diagnosis of DIE (P < 0.05). Multivariate analysis showed that women with any siblings, gastrointestinal symptoms during menstruation, or eating a greater number of fruit/vegetables per day were more likely to be diagnosed with DIE. Meanwhile, eating organic food and experiencing stress were major factors that are associated with the diagnosis of OMA.

CONCLUSIONS

The findings provide additional information on the potential risk factors that are associated with DIE, compared with OMA among Chinese endometriosis patients. The results may help to better understand DIE versus OMA, and aid in earlier risk stratification and diagnosis of the patients.

TRIAL REGISTRATION

NCT01351051 . Registered 10 May 2011.

Endometrioma-related reduction in ovarian reserve (ERROR): a prospective longitudinal study

OBJECTIVE

To evaluate whether endometrioma is associated with a progressive decline in ovarian reserve, and to compare the rate of decline with natural decline in ovarian reserve.

DESIGN

Prospective, observational study.

SETTING

Tertiary university hospital, endometriosis clinic.

PATIENT(S)

Forty women with endometrioma and 40 age-matched healthy controls.

INTERVENTION(S)

Women with endometriomas who did not need hormonal/surgical treatment at the time of recruitment and were expectantly managed. Controls were age-matched, healthy women. All participants underwent serum antimüllerian hormone (AMH) testing twice, 6 months apart. Sexually active patients with endometrioma also underwent antral follicle count.

MAIN OUTCOME MEASURE(S)

Change in serum AMH levels.

RESULT(S)

Median (25th-75th percentile) serum AMH level at recruitment was 2.83 (0.70-4.96) ng/mL in the endometrioma group and 4.42 (2.26-5.57) ng/mL in the control group. The median percent decline in serum AMH level was 26.4% (11.36%-55.41%) in the endometrioma group and 7.4% (-11.98%, 29.33%) in the control groups. Twenty-two women with endometrioma who had antral follicle count (AFC) had median AFC of 10 (8-12) at recruitment and 8 (6.3-10) at 6 months.

CONCLUSION(S)

Women with endometrioma experience a progressive decline in serum AMH levels, which is faster than that in healthy women.

CLINICAL TRIAL REGISTRATION NUMBER

NCT02438735.

The DNA methylation status of genes encoding Matrix metalloproteinases and tissue inhibitors of Matrix metalloproteinases in endometriosis

Endometriosis is a benign disease, with malignant properties. A necessary step in the progression of endometriosis is tissue remodeling, which is coordinated by the activities of matrix metalloproteinases (MMPs) and tissue inhibitors of matrix metalloproteinases (TIMPs). This study evaluated the regulation of abnormal MMP and TIMP gene expression during endometriosis. Among the two genes families, promoter regions of MMP2, MMP3, MMP7, TIMP3, and TIMP4 were significantly altered in proliferative-phase endometriotic lesions compared to menstrual cycle-matched eutopic tissue from endometriosis-free women. In addition, a negative correlation was found between the DNA methylation status of the promoter region and transcript abundance of MMP2. Our findings suggest that changes in DNA methylation at the promoter region of MMP2 could underlie the changes in its expression in the ectopic endometria from patients with endometriosis.

Saridogan E, Becker CM, Feki A, Grimbizis GF, Hummelshoj L, Keckstein J, Nisolle M, Tanos V, Ulrich UA, Vermeulen N, De Wilde RL. Recommendations for the surgical treatment of endometriosis-part 1: ovarian endometrioma

Study question

What does this document on the surgical treatment of endometriosis jointly prepared by the European Society for Gynaecological Endoscopy (ESGE), ESHRE, and the World Endometriosis Society (WES) provide?

Summary answer

This document provides recommendations covering technical aspects of different methods of surgery for endometriomas in women of reproductive age.

What is already known

Endometriomas (ovarian endometriotic cysts) are a commonly diagnosed form of endometriosis, owing to the relative ease and accuracy of ultrasound diagnosis. They frequently present a clinical dilemma as to whether and how to treat them when found during imaging or incidentally during surgery. Previously published guidelines have provided recommendations based on the best available evidence, but without technical details on the management of endometriosis.

Study design size and duration

A working group of ESGE, ESHRE and WES collaborated on writing recommendations on the practical aspects of endometrioma surgery.

Participants/materials setting and methods

This document focused on endometrioma surgery. Further documents in this series will provide recommendations for surgery of deep and peritoneal endometriosis.

Main results and the role of chance

The document presents general recommendations for surgery of endometrioma and specific recommendations for cystectomy, ablation by laser or by plasma energy, electrocoagulation and a combination of these techniques applied together or with an interval between them.

Limitations and reasons for caution

Owing to the limited evidence available, recommendations are mostly based on clinical expertise.

Wider implications of the findings

These recommendations complement previous guidelines on the management of endometriosis.

Study funding/competing interests

The meetings of the working group were funded by ESGE, ESHRE and WES. CB declares to be a member of the independent data monitoring committee for a clinical study by ObsEva and receiving research grants from Bayer, Roche Diagnostics, MDNA Life Sciences and Volition. ES received honoraria for provision of training to healthcare professionals from Ethicon, Olympus and Gedeon Richter. The other authors declare that they have no conflict of interest.

Saridogan E, Becker CM, Feki A, Grimbizis GF, Hummelshoj L, Keckstein J, Nisolle M, Tanos V, Ulrich UA, Vermeulen N, De Wilde RL. Recommendations for the Surgical Treatment of Endometriosis. Part 1: Ovarian Endometrioma

STUDY QUESTION

What does this document on the surgical treatment of endometriosis jointly prepared by the European Society for Gynaecological Endoscopy (ESGE), ESHRE, and the World Endometriosis Society (WES) provide?

SUMMARY ANSWER

This document provides recommendations covering technical aspects of different methods of surgery for endometriomas in women of reproductive age.

WHAT IS ALREADY KNOWN

Endometriomas (ovarian endometriotic cysts) are a commonly diagnosed form of endometriosis, owing to the relative ease and accuracy of ultrasound diagnosis. They frequently present a clinical dilemma as to whether and how to treat them when found during imaging or incidentally during surgery. Previously published guidelines have provided recommendations based on the best available evidence, but without technical details on the management of endometriosis.

STUDY DESIGN SIZE DURATION

A working group of ESGE, ESHRE and WES collaborated on writing recommendations on the practical aspects of endometrioma surgery.

PARTICIPANTS/MATERIALS SETTING METHODS

This document focused on endometrioma surgery. Further documents in this series will provide recommendations for surgery of deep and peritoneal endometriosis.

MAIN RESULTS AND THE ROLE OF CHANCE

The document presents general recommendations for surgery of endometrioma, and specific recommendations for cystectomy, ablation by laser or by plasma energy, electrocoagulation and a combination of these techniques applied together or with an interval between them.

LIMITATIONS REASONS FOR CAUTION

Owing to the limited evidence available, recommendations are mostly based on clinical expertise.

WIDER IMPLICATIONS OF THE FINDINGS

These recommendations complement previous guidelines on the management of endometriosis.

STUDY FUNDING/COMPETING INTERESTS

The meetings of the working group were funded by ESGE, ESHRE and WES. C.B. declares to be a member of the independent data monitoring committee for a clinical study by ObsEva, and receiving research grants from Bayer, Roche Diagnostics, MDNA Life Sciences, and Volition. E.S. received honoraria for provision of training to healthcare professionals from Ethicon, Olympus and Gedeon Richter. The other authors declare that they have no conflict of interest.

TRIAL REGISTRATION NUMBER

NA.

Co-existence of benign gynecological tumors with endometriosis in a group of 1,000 women

The purpose of this study was two-fold, first to investigate the association between endometriosis and the risk of benign gynecologic tumors and, secondly, to evaluate the distribution of endometrioma and ovarian cysts in women with endometriosis. The medical and pathological reports of 1,000 women with endometriosis were retrospectively reviewed. The incidence of ovarian cysts, uterine leiomyomas and adenomyosis, as well as the side of ovarian cysts were further compared. A total of 295 cases of endometriomas, 172 cases of adenomyosis, 173 cases of ovarian cysts and 89 cases of uterine leiomyomas were confirmed histologically in patients with endometriosis. Serous cysts represented the most frequent diagnosis (n=81, 8.1%) in women with ovarian cysts, followed by dermoid cysts (n=15, 1.2%). In women with unilateral endometriomas, the observed proportion of left-sided cysts was found in 65.6% (164 of 250), significantly higher compared with right-sided cysts (86 out of 250, 34.4%) (P<0.001). Moreover, patients with other ovarian cysts were recognized as left-sided in 60% (96 out of 160) of cases, significantly higher compared with right-sided cysts (64 out of 160, 40%) (P<0.01). On the whole, the current study indicates that endometriosis may be associated with an increased risk of benign gynecological tumors, such as ovarian cysts, adenomyosis and leiomyomas. The results of this study confirm a left lateral predisposition of endometriomas and ovarian cysts.