Uterine anomalies and endometriosis

Clinical characteristics and treatment outcomes of patients with a septate uterus complicated by endometriosis

OBJECTIVES

Patients with a septate uterus often have endometriosis, which can exacerbate their adverse pregnancy outcomes. We aimed to describe the clinical characteristics and treatment outcomes of patients with a septate uterus complicated by endometriosis.

STUDY DESIGN

This retrospective study included patients who had a septate uterus complicated by endometriosis and were treated in Wuhan Tongji Hospital in the past 10 years. The characteristics of patients with a septate uterus and endometriosis were collected and described in terms of their preoperative and postoperative pregnancy outcomes.

RESULTS

There were 24 cases with a complete septate uterus and 49 cases with an incomplete septate uterus.Combinations of other malformations are more common in patients with complete septate uterus. In patients with a septate uterus, endometriosis often affected the ovaries, most commonly the left side (P<0.001). Non-significant difference in the staging of endometriosis between complete and incomplete septate uterus (P=0.812). Surgical treatment greatly improved the reproductive function and increased the live birth rate of patients with a septate uterus complicated by endometriosis (P<0.001).

CONCLUSIONS

Compared to a septate uterus uncomplicated endometriosis, a septate uterus complicated by endometriosis significantly affects reproductive function. Surgical treatment can significantly improve the pregnancy outcomes of patients with a septate uterus and endometriosis. Clinicians should pay attention to timely diagnosing and treating these patients.

Reproductive outcomes of oocyte donation in patients with uterine Müllerian anomalies

OBJECTIVE

To evaluate live-birth rates per embryo transfer in patients with uterine Müllerian anomalies (UMAs). Secondary objectives were to compare reproductive outcomes between the normal uterus group, the different UMA types, and UMA subgroups with and without required surgery.

DESIGN

This retrospective study compared two cohorts, one with UMAs and other with normal uteri of our oocyte donation program at 12 Instituto Valenciano De Infertilidad/Reproductive Medicine Associates University affiliated clinics from January 2000 to 2020. The oocyte donation reduces confounding because of differences in embryo quality. The primary outcome was the live-birth rate per embryo transfer. Secondary outcomes included the rates of implantation, clinical pregnancy, miscarriage, and ongoing pregnancy. We calculated odds ratios with 95% confidence intervals.

PATIENTS

Infertile women undergoing oocyte donation with UMAs.

INTERVENTION

None.

MAIN OUTCOME MEASURES

The rates of implantation, clinical pregnancy, miscarriage, ongoing pregnancy, and live birth.

RESULTS

We analyzed 58,337 cycles of oocyte donation: 57,869 patients had no uterine malformation, and 468 women had UMAs. Compared with patients with normal uteri, patients with UMAs had lower rates of live births (36.67% [32.84-40.65] vs. 38.1% [95% confidence intervals {CI}: 37.82-38.42]) and ongoing pregnancy (39.74% [35.93-43.66] vs. 41.5% [41.24-41.83]). The miscarriage rate was higher in patients with UMAs (19.5% [16.55-22.85] vs. 16.6% [16.47-16.92]). Specifically, patients with a unicornuate uterus (n=29) had lower rates of implantation (24.07% [13.49-37.64] vs. 42.85% [95% CI: 42.6-43.09]), pregnancy (41.86% [27.01-57.87] vs. 59.51% [59.22-59.81]), ongoing pregnancy (16.67% [6.97-31.36] vs. 41.54% [41.24-41.83]), and live births (16.67% [6.97-31.36] vs. 38.12% [37.83-38.42]). In addition, patients with a partial septate uterus (n=91) had a higher miscarriage rate (26.50% [18.44-34.89] vs. 16.7% [16.47-16.92]). Compared with the normal uterus group, the live-birth rates were lower in the UMA without surgery group (33.09% [27.59-38.96] vs. 38.12% [37.83-38.42]).

CONCLUSION

Among patients who received embryos derived from donated oocytes, live birth and ongoing pregnancy rates were lower in patients with UMAs compared with patients with normal uteri. A higher miscarriage rate was found in patients with UMAs. Patients with a unicornuate uterus had worse reproductive outcomes. Our results show that the uterus is less competent in patients with UMAs.

TRIAL REGISTRATION

This study was registered at clinicaltrial.gov (NCT04571671).

Total or Subtotal Hysterectomy for the Treatment of Endometriosis: A Review

OBJECTIVE

The purpose of the review was to evaluate and compare outcomes after total or subtotal hysterectomy in women with endometriosis or adenomyosis.

METHODS

We searched four electronic databases: Medline (PubMed), Scopus, Embase, and Web of Science (WoS). The first aim of the study was to compare outcomes after total and subtotal hysterectomy in women with endometriosis, and the second aim was to compare the two procedures in women with adenomyosis. Publications that reported short- and long-term outcomes after total and subtotal hysterectomy were included in the review. The search was not subject to any limitation in terms of time or method.

RESULTS

After screening 4948 records, we included 35 studies published from 1988 to 2021; the studies were based on various methodologies. With regard to the first aim of the review, we found 32 eligible studies and divided these into the following four categories: postoperative short- and long-term outcomes, recurrence of endometriosis, quality of life and sexual function, and patient satisfaction after total or subtotal hysterectomy in women with endometriosis. Five investigations were deemed eligible for the second aim of the review. No differences were seen in terms of postoperative short- and long-term outcomes after subtotal or total hysterectomy in women with endometriosis or adenomyosis.

CONCLUSIONS

Preservation or removal of the cervix in women with endometriosis or adenomyosis appears to have no effect on short- or long-term outcomes, recurrence of endometriosis, quality of life and sexual function, or patient satisfaction. Nevertheless, we lack randomized blinded controlled trials on these aspects. Such trials will be needed to enhance our comprehension of both surgical approaches.

Concurrent Diagnosis of Adenomyosis and Congenital Uterine Anomalies: A Review

Background: Adenomyosis and congenital uterine anomalies (CUAs) can compromise reproductive potential and may coexist in the same patient, especially in cases of infertility. This review (CRD42022382850) aims to evaluate the published cases of concurrent adenomyosis and syndromic and nonsyndromic CUAs. Methods: A literature search for suitable articles published in the English language was performed using the following databases from inception to 30 November 2022: MEDLINE, EMBASE, Global Health, the Cochrane Library, Health Technology Assessment Database, and Web of Science. Articles including both CUAs and adenomyosis, with data about their potential relationship, were included. Results: The literature search retrieved 14 articles that met the purpose of this review and summarized the most recent findings regarding the concurrent diagnosis of adenomyosis and CUAs. Conclusions: Adenomyosis can be found in both syndromic and nonsyndromic CUAs, and may arise from several etiologies. The hypothesis that obstructions in CUAs increase uterine pressure and promote the development of adenomyosis remains to be further elucidated, and additional findings may also play a role. The patient's genetic, epigenetic, and hormonal patterns, as well as normal physiological processes, such as pregnancy, may influence the growth of adenomyosis.

Reconsidering the best minimally invasive approach for patients with herlyn-werner-wunderlich syndrome: Should we push the frontiers for a better outcome?

Obstructed hemivagina and ipsilateral renal agenesis (OHVIRA) syndrome is a rare congenital defect of the Mullerian ducts characterized by uterine didelphys, unilateral obstructed hemivagina, and ipsilateral renal agenesis. It frequently presents during puberty, with complications such as pelvic pain, pelvic inflammatory disease and infertility. Surgical management is the mainstay treatment. A vaginal access for septum resection is usually used. However, it can be in difficult in several situations such as a very proximal septum with a small bulge, or in the case of virgin patients with social considerations regarding the hymenal ring integrity. Thus, a laparoscopic approach may be a beneficial alternative. In particular, laparoscopic hemi hysterectomy has recently gained remarkable interest due to its added benefit of treating the cause rather than treating only the symptoms. It removes the source of the bleeding, thus stopping the flow. However, it transforms a bicornuate uterus into a unicornuate uterus, leading to some obstetrical concerns. Should we push the frontiers further and consider laparoscopic hemi hysterectomy for better outcomes as the mainstay management of patients with OHVIRA syndrome?

Impact of Adenomyosis on Infertile Patients-Therapy Options and Reproductive Outcomes

Adenomyosis is associated with a negative impact on reproductive outcomes. Although adenomyosis is detected more frequently in women of late reproductive age, its impact on pregnancy rates is important because, in today's world, family planning has shifted towards the late reproductive phase of life for many women. Although the diagnostic indications for imaging studies are well-known, we lack strict diagnostic criteria and classification systems concerning the extent of the disease. Selecting the optimal evidence-based treatment option for adenomyosis is difficult because of the paucity of evidence concerning the association between fertility and the degree and composition of adenomyosis. Furthermore, the treatment of infertility might interfere with the treatment of adenomyosis due to the presence of pain. The aim of this review is to analyze the association between adenomyosis and infertility, and describe treatment options to enhance reproductive outcomes. The following aspects will be addressed in detail: (a) prevalence and causes of adenomyosis, (b) diagnostic tools with imaging techniques, (c) clinical symptoms, (d) proposed pathomechanism of adenomyosis and infertility, and (e) different treatment approaches (pharmacological, surgical, others) and their impact on reproductive outcomes.

Clinical and Genetic Characteristics of a Cohort with Distal Vaginal Atresia

Distal vaginal atresia is a rare abnormality of female reproductive tract in which the vagina is closed or absent. The distal vagina may be replaced by fibrous tissue and the condition is often not diagnosed until a girl fails to begin having periods at puberty. Although it is a congenital disorder, potential genetic causes of distal vaginal atresia are still unknown. We recruited a cohort of 39 patients with distal vaginal atresia and analyzed their phenotypic and genetic features. In addition to the complaint of distal vaginal atresia, approximately 17.9% (7/39) of the patients had other Müllerian anomalies, and 17.9% (7/39) of the patients had other structural abnormalities, including renal-tract, skeletal and cardiac anomalies. Using genome sequencing, we identified two fragment duplications on 17q12 encompassing HNF1B and LHX1, two dosage-sensitive genes with candidate pathogenic variants, in two unrelated patients. A large fragment of uniparental disomy was detected in another patient, affecting genes involved in cell morphogenesis and connective tissue development. Additionally, we reported two variants on TBX3 and AXL, leading to distal vaginal atresia in mutated mouse model, in our clinical subjects for the first time. Essential biological functions of these detected genes with pathogenic variants included regulating reproductive development and cell fate and patterning during embryogenesis. We displayed the comprehensive clinical and genetic characteristic of a cohort with distal vaginal atresia and they were highly heterogeneous both phenotypically and genetically. The duplication of 17q12 in our cohort could help to expand its phenotypic spectrum and potential contribution to the distal vaginal atresia. Our findings of pathogenic genetic variants and associated phenotypes in our cohort could provide evidence and new insight for further research attempting to reveal genetic causes of distal vaginal atresia.

Clinical Features and Management of Endometriosis among Patients with MRKH and Functional Uterine Remnants

OBJECTIVE

To determine the clinical features of Mayer-Rokitansky-Küster-Hauser syndrome (MRKH) patients with functional uterine remnants and endometriosis in a large cohort of Chinese patients.

DESIGN

This was a retrospective study.

PARTICIPANTS

This study had a cohort of 511 MRKH patients. A total of 34 MRKH patients with functional remnant were finally included.

SETTING

Tertiary referring hospitals in China.

METHODS

Patients with MRKH diagnosed and treated at Peking Union Medical College Hospital from January 2009 to January 2020 were recruited. A cohort of 511 MRKH patients were retrospectively screened and a total of 34 MRKH patients with functional remnant were finally included. Relevant clinical data were reviewed retrospectively from medical charts.

RESULTS

Of 34 patients with MRKH and functional uterine remnants, 23 (68%) had endometriosis. These patients had a greater mean age at MRKH diagnosis than patients without endometriosis (15.9 ± 3.3 years vs 13.2 ± 3.5 years; P=0.03). Similarly, these patients experienced a longer time between age at onset of symptoms and age at operation than patients without endometriosis (45.5 ± 39.6 years vs 19.8 ± 13.2 years; P =0.04). In addition, the CA125 level was significantly higher in patients with endometriosis than in those without it (64.9 ± 85.9 U/ml vs 25.5 ± 19.1 U/ml; P = 0.03).

LIMITATIONS

The number of patients with MRKH analyzed in this study was low as we restricted inclusion to patients with at least one functional uterine remnant or endometriosis.

CONCLUSIONS

It is reasonable to monitor the uterine remnant of patients with MRKH closely, regardless of age, to achieve early intervention. The level of CA125 might be helpful to differentiate active uterine remnants with endometriosis and schedule individualized treatments.

Challenges Posed by Embryonic and Anatomical Factors in Systematic Lymphadenectomy for Endometrial Cancer

Lymph node involvement has been shown to be one of the most relevant prognostic factors in a variety of malignancies; this is also true of endometrial cancer. The determination of the lymph node status is crucial in order to establish the tumor stage, and to consider adjuvant treatment. A wide range of surgical staging practices are currently used for the treatment of endometrial cancer. The necessity and extent of lymph node dissection is an ongoing controversial issue in gynecological oncology. Lymph node surgery in endometrial cancer is technically challenging, and can be time consuming because of the topographic complexity of lymphatic drainage as such, and the fact that the lymph nodes are directly adjacent to both blood vessels and nerves. Therefore, profound and exact knowledge of the anatomy is essential. Sentinel lymph node mapping was recently introduced in surgical staging with the aim of reducing morbidity, whilst also obtaining useful prognostic information from a patient’s lymph node status. The present review summarizes the current evidence on the role of lymph node surgery in endometrial cancer, focusing on the embryological, anatomical, and technical aspects.

BIRC5/Survivin Expression as a Non-Invasive Biomarker of Endometriosis

The etiology of endometriosis is highly complex, and although it is a benign disease, it has several biological behaviors similar to malignant lesions, including cell invasion, neo-angiogenesis, and decreased apoptosis. Survivin is a protein encoded by the BIRC5 gene that plays a role in cell division by inhibiting apoptosis and regulating the process of mitosis in embryonic and cancer cells. Therefore, we aimed to evaluate the expression of BIRC5 in samples of peripheral blood of women with and without endometriosis. This study comprised of 40 women with endometriosis and 10 healthy women as controls. Peripheral blood samples were collected in the three phases of the menstrual cycle (follicular, ovulatory, and luteal). The expression of the BIRC5 gene was evaluated by RT-qPCR using the TaqMan methodology. The BIRC5 expression was significantly higher in all phases of the menstrual cycle in women with endometriosis, regardless of the disease stage. The accuracy of BIRC5 expression in the peripheral blood for the diagnosis endometriosis presented AUC of 0.887 (p < 0.001), with 97.2% of sensitivity and specificity of 65.5% considering the overall endometriosis group. Regarding the minimal/mild endometriosis group, the AUC presented a value of 0.925 (p < 0.001), with 100% of sensitivity and 79.3% of specificity, whereas in the moderate/severe endometriosis group the AUC was 0.868 (p < 0.001), with a sensitivity of 95.8% and specificity of 65.5%. These findings suggest that the expression of BIRC5 may be a potential noninvasive biomarker for the diagnosis of endometriosis.