Infertile Women with Deep and Intraperitoneal Endometriosis: Comparison of Fertility Outcome According to the Extent of Surgery

doi:10.1016/j.jmig.2011.06.004

Journal of Minimally Invasive Gynecology

Volume 18, Issue 5, September–October 2011, Pages 622-628

https://doi.org/10.1016/j.jmig.2011.06.004 Get rights and content

Abstract

Study Objective

This study was undertaken to ascertain whether the incidence of spontaneous pregnancy is increased in infertile women with deep and intraperitoneal endometriosis undergoing extensive surgery compared with those undergoing only intraperitoneal surgery.

Design

Retrospective case control study (Canadian Task Force classification II-1).

Setting

University teaching hospital.

Patients

Infertile women under the age of 40 years with deep and intraperitoneal endometriosis and no other associated major infertility factors. Only patients with at least 1 year of postoperative follow-up were included.

Interventions

Intraperitoneal surgery only (group 1) or extensive surgery (group 2) according to a shared decision-making approach.

Measurements and Main Results

Among the 34 women in group 1, 6 became pregnant, compared with 8 of the 41 women who had extensive surgery (12-month cumulative probabilities, 24.8% and 11.4%, respectively, and 24-month cumulative probabilities, 24.8% and 23.2%, respectively; p = .82). Perioperative surgical complication rate was higher in group 2 (6/41 versus 0/34; p = .02).

Conclusion

Extensive surgery for intraperitoneal and deep endometriosis in infertile women does not modify global fertility outcome but is associated with a higher complication rate.

Section snippets

Materials and Methods

We considered consecutive women under the age of 40 years with intraperitoneal and deep endometriosis operated on in our institution, between April 2000 and November 2008, who had tried to conceive without success for 12 months or longer and had no other obvious cause of infertility. The diagnostic workup included ovarian reserve evaluation (i.e., anti-Mullerian hormone, follicle-stimulating hormone and estradiol serum testing on day 3 of the cycle), hysterosalpingography, and semen analysis of

Results

Of the 75 patients who met the inclusion criteria, 34 preferred intraperitoneal surgery only (group 1) and 41 extensive surgical treatment (group 2). The baseline clinical characteristics of the women enrolled in the study are shown in Table 1. The distribution of the considered variables, which included factors that affect reproductive prognosis (age, nulliparity, previous pelvic surgery and type of infertility), as well as pain symptom severity and CA125 value, were similar in the two groups.

Discussion

We conducted a retrospective comparative analysis of patients with intraperitoneal and deep endometriosis to ascertain if surgery of deep endometriosis is associated with fertility improvement. The decision to perform retroperitoneal surgery for deep endometriosis in infertile women with few symptoms is strongly debated. When infertility is the main problem, the decision to perform surgery is often difficult to take and very few data are available in such cases concerning a hypothetical

Conclusion

Studies on deep endometriosis focus mainly on pain relief 15, 16, 30, 31, whereas information on reproductive performance in infertile women is scant 32, 33, 34. The functional results of surgery for endometriosis indicate through various studies that optimal management requires extensive surgery and that extensive surgery does increase pain-free survival time 5, 15, 16, 32, 33. However, on the basis of the findings of this study, we should consider that, in infertile women with intraperitoneal

References (34)

H. Suginami et al.
An ovum capture inhibitor (OCI) in endometriosis peritoneal fluid: an OCI-related membrane responsible for fimbrial failure of ovum capture
Fertil Steril
(1988)
D.I. Lebovic et al.
Immunobiology of endometriosis
Fertil Steril
(2001)
P. Vercellini et al.
Reproductive performance in infertile women with rectovaginal endometriosis: is surgery worthwhile?
Am J Obstet Gynecol
(2006)
P. Vercellini et al.
Endometriosis and pelvic pain: relation to disease stage and localization
Fertil Steril
(1996)
A. Fauconnier et al.
Relation between pain symptoms and the anatomic location of deep infiltrating endometriosis
Fertil Steril
(2002)
L. Muzii et al.
Correlation between endometriosis-associated dysmenorrhea and the presence of typical or atypical lesions
Fertil Steril
(1997)
D.L. Frosch et al.
Shared decision making in clinical medicine: past research and future directions
Am J Prev Med
(1999)
P. Vercellini et al.
Deep endometriosis: definition, pathogenesis, and clinical management
J Am Assoc Gynecol Laparosc
(2004)
L. Fedele et al.
Long-term follow-up after conservative surgery for rectovaginal endometriosis
Am J Obstet Gynecol
(2004)
L. Muzii et al.
Laparoscopic excision of ovarian cysts: is the stripping technique a tissue-sparing procedure?
Fertil Steril
(2002)

C. Yazbeck et al.

Ethanol sclerotherapy: a treatment option for ovarian endometriomas before ovarian stimulation

Reprod Biomed Online

(2009)

P.A. Ribeiro et al.

Laparoscopic resection of intestinal endometriosis: a 5-year experience

J Minim Invasive Gynecol

(2006)

L. Mereu et al.

Laparoscopic treatment of deep endometriosis with segmental colorectal resection: short-term morbidity

J Minim Invasive Gynecol

(2007)

V. Anaf et al.

Impact of surgical resection of rectovaginal pouch of Douglas endometriotic nodules on pelvic pain and some elements of patients’ sex life

J Am Assoc Gynecol Laparosc

(2001)

M. Possover et al.

Laparoscopically assisted vaginal resection of rectovaginal endometriosis

Obstet Gynecol

(2000)

D.B. Redwine et al.

Laparoscopic treatment of complete obliteration of the cul-de-sac associated with endometriosis: long-term follow-up of en bloc resection

Fertil Steril

(2001)

L. Fedele et al.

Is rectovaginal endometriosis a progressive disease?

Am J Obstet Gynecol

(2004)

Cited by (28)

Controversies in the treatment of endometriosis in sterile women
2023, Clinica e Investigacion en Ginecologia y Obstetricia
La endometriosis es una enfermedad muy compleja que limita la vida de las mujeres que la padecen en muchos ámbitos, tanto por la clínica dolorosa que provoca como por las complicaciones médicas que genera. Además, es capaz de provocar esterilidad por diferentes mecanismos.
En el presente trabajo pretendemos revisar el manejo de la paciente con endometriosis y esterilidad que tiene particularidades importantes respecto al tratamiento habitual de la endometriosis. La mayoría de los tratamientos médicos utilizados tienen efecto anovulatorio, por lo que impiden la gestación, y los tratamientos quirúrgicos pueden tener a su vez un efecto perjudicial sobre la reserva ovárica y el tiempo necesario para alcanzar la gestación. Por otro lado, las técnicas de reproducción asistida no siempre logran el objetivo deseado y pueden requerir la realización de cirugías asociadas, como en el caso de presencia de hidrosalpinx o de ovarios no accesibles a la punción folicular.
También realizamos una revisión crítica de la literatura médica y de las guías de las distintas sociedades científicas para tratar de establecer unos criterios generales sobre el abordaje de estas pacientes con endometriosis y esterilidad que, como regla general, deberían ser tratadas mediante técnicas de reproducción asistida. Se realiza un especial análisis de las situaciones específicas en las que se requiere un abordaje diferenciado con cirugía previa cuando está en peligro la función de algún órgano pélvico o en la endometriosis profunda.
Endometriosis is a very complex disease that limits the lives of women who suffer from it in many areas of their lives, both due to the painful symptoms it causes and the medical complications it generates. In addition, it is capable of causing sterility by different mechanisms.
In the present work we intend to review the management of the patient with endometriosis and sterility, which has important particularities with respect to the usual treatment of endometriosis. Most of the medical treatments used have an anovulatory effect, which is why they prevent pregnancy, and surgical treatments can in turn have a detrimental effect on the ovarian reserve and the time necessary to achieve pregnancy. On the other hand, assisted reproduction techniques do not always achieve the desired objective and may require associated surgeries such as in the case of the presence of hydrosalpinx or ovaries not accessible to follicular puncture.
We also carried out a critical review of the medical literature and the guidelines of the different scientific societies to try to establish general criteria for the approach to these patients with endometriosis and sterility, who as a general rule should be treated by assisted reproductive techniques. A special analysis is made of the specific situations in which a differentiated approach with previous surgery is required when the function of a pelvic organ is in danger or in deep endometriosis.
Comparison of Clinical and Reproductive Outcomes between Adenomyomectomy and Myomectomy
2022, Journal of Minimally Invasive Gynecology
Citation Excerpt :
It is unsure how much the surgical resection of endometriosis modifies the reproductive prognosis. However, it is usually accepted that women desiring future fertility who suffer from pain may benefit from the surgical management [28]. In our approach to all the patients, if endometriosis was found, it was resected (as a part of adenomyomectomy or myomectomy) to minimize its influence on fertility.
Women with adenomyosis may show a lower pregnancy rate and a higher miscarriage rate than healthy women. There is also a general agreement that leiomyomas, either submucosal or intramural, negatively affect fertility, when compared with women without myomas. Some of these women may benefit from adenomyomectomy, however this cytoreductive procedure is considered invasive and technically challenging especially in severe diffuse cases. The study aimed to compare the clinical and reproductive outcomes of patients who underwent adenomyomectomy with those of patients who underwent intramural myomectomy.
A retrospective study.
Department of Obstetrics & Gynecology, Center of Gynecological Endoscopy and Minimally Invasive surgery, First Faculty of Medicine, General University Hospital in Prague.
A total of 55 women who underwent surgical resection of uterine adenomyosis and 55 patients who underwent myomectomy for intramural uterine myomas were included in this study. All study participants wished to retain and possibly improve their reproductive potential.
Between 2004 and 2019, 110 women underwent laparoscopic or open uterus-sparing surgery for clinically significant uterine adenomyosis (group A) or myomas (group B), respectively.
Two groups of women who underwent different fertility-saving procedures were compared. Although all women entering the study had declared their wish to conceive, only 28 patients in group A (group A1) and 24 women in group B (group B1) finally aimed toward pregnancy. The mean age and follow-up period was 35.0 years and 76.81 months, respectively, in group A and 34.8 years and 72.5 months, respectively, in group B. The pregnancy and delivery rates were 75.0% and 46.4%, respectively, in group A1 vs 96.0% and 70.8%, respectively, in group B1, with no significant differences between the 2 groups. The open surgical approach was significantly more frequently employed in group A (47.3% vs 16.4%; p <.01).
In this study, women who underwent surgery involving the uterine muscularity, including myomectomy or adenomyomectomy, had comparable reproductive outcomes, with no significant differences.
Management of Endometriosis: Toward Value-Based, Cost-Effective, Affordable Care
2018, Journal of Obstetrics and Gynaecology Canada
Endometriosis management seems to be influenced by outcome-independent biomedical, pharmacological, and technological developments. The propensity towards doing more affects several aspects of care, sometimes translating into proposals that are not based on sound epidemiological principles and robust evidence. Different stakeholders share the interest for doing more testing and using novel and costly drugs or devices in patients with endometriosis. Although some women may benefit from such an approach, the majority do not, and some may be harmed. Moreover, an uncontrolled increase in expenditures for endometriosis management without demonstrated and proportional health benefits would waste the finite resources of national health care services and would risk cost-related non-adherence. Cost-effectiveness analyses should be systematically pre-planned in future trials on endometriosis, and the concept of “value” of medical interventions should guide investigators and health care policymakers. Reducing low-value care, financial toxicity, and the burden of treatment is respectful not only of endometriosis patients, but also of the entire society. Whenever possible, long-term therapeutic strategies should be tailored to each woman's needs, and high-value tests and treatments should be chosen based on her priorities and preferences. Moreover, listening to patients, understanding their concerns, avoiding disease labelling, explaining plainly what is known and what is unknown, and giving constant reassurance and encouragement may be exceedingly important for the successful management of endometriosis and may change the patient's perception of her clinical condition. Physician empathy has no untoward effects, does not cause harms, and may determine whether a woman successfully copes or desperately struggles with her disease during reproductive life.
La prise en charge de l'endométriose semble être influencée par des avancées biomédicales, pharmacologiques et technologiques, indépendamment des issues cliniques. La tendance à multiplier les interventions affecte plusieurs aspects des soins et entraîne parfois des propositions ne reposant pas sur des principes épidémiologiques ni sur des données probantes solides. Différents intervenants peuvent avoir intérêt à recourir à de nombreuses analyses et à proposer de nouveaux médicaments et appareils coûteux pour traiter les patientes atteintes d'endométriose. Si certaines femmes peuvent être avantagées par une approche de ce type, ce n'est pas le cas pour la majorité : d'autres peuvent même subir des préjudices. De plus, une hausse non contrôlée des dépenses liées à la prise en charge de l'endométriose en l'absence de bienfaits proportionnels et démontrés pour la santé viendrait gruger les ressources limitées des systèmes nationaux de soins de santé et pourrait entraîner une non-observance des traitements en raison de leurs coûts. Des analyses de coût-efficacité devraient automatiquement être intégrées à la planification des futurs essais sur l'endométriose, et le concept de « valeur » des interventions médicales devrait orienter les chercheurs et les responsables des politiques dans le domaine des soins de santé. La réduction de la prestation de soins de faible valeur, de la toxicité financière et du fardeau associé aux traitements profiterait non seulement aux patientes atteintes d'endométriose, mais aussi à l'ensemble de la société. Dans la mesure du possible, les stratégies de traitement à long terme devraient être adaptées pour répondre aux besoins de chaque femme. Il faudrait également choisir les examens et les traitements de grande valeur en fonction des priorités et des préférences des patientes. Qui plus est, le fait d'écouter les patientes, de comprendre leurs préoccupations, d'éviter de mettre une étiquette sur leur maladie, d'expliquer le plus simplement possible les éléments connus et inconnus et de leur fournir constamment réconfort et encouragement peut être l'aspect le plus important d'une prise en charge efficace de l'endométriose et peut changer la perception des patientes à l'égard de leur état. La compassion démontrée par le médecin n'a aucun effet fâcheux, ne cause aucun dommage et peut aider une femme à bien gérer sa maladie durant sa vie génésique au lieu d'éprouver de grandes difficultés.
Bowel endometriosis and infertility: Do we need to operate?
2017, Gynecologie Obstetrique Fertilite et Senologie
L’endométriose, pathologie bénigne inflammatoire dont la physiopathologie reste mal élucidée, est source de douleurs pelviennes et d’infertilité. Une des caractéristiques principales de l’endométriose est son hétérogénéité clinique et anatomique (lésions péritonéales superficielles, ovariennes et/ou profondes infiltrantes). Parmi les atteintes profondes, une forme particulièrement sévère est l’atteinte digestive. Elle est retrouvée chez 8–12 % des patientes présentant une endométriose profonde. Cette atteinte, surtout en cas d’infertilité associée, constitue un réel challenge pour le gynécologue, posant la délicate question de la conduite à tenir au plan thérapeutique. En effet, l’exérèse chirurgicale complète des lésions, bien qu’efficace sur les douleurs et semblant améliorer la fertilité spontanée, implique des gestes techniquement difficiles et présente un risque non négligeable de complications sévères. Le recours à l’assistance médicale à la procréation (AMP) constitue une alternative pertinente pour améliorer les chances de grossesse. Le choix entre les deux stratégies thérapeutiques est donc très débattu. Les bénéfices et risques de ces deux options doivent être pris en considération et expliqués au couple. L’objectif de ce travail est d’apporter des éléments de réponse à la question suivante : Faut-t-il opérer les patientes infertiles présentant une endométriose digestive ?
Endometriosis is a benign chronic inflammatory disease, whose pathogenesis is still unclear. Endometriosis is responsible for infertility and/or pelvic pain. One of the most important features of the disease is the heterogeneity (clinical and anatomical: superficial peritoneal, ovarian and/or deep infiltrating lesions). Bowel involvement constitutes one particularly severe form of the disease, affecting 8–12% of women with deep endometriosis. In case of associated infertility, bowel endometriosis constitutes a real therapeutic challenge for gynecologists. Indeed, while complete resection of the lesions alleviates pain and seems to improve spontaneous fertility, surgery remains technically challenging and may cause severe complications. Reverting to assisted Reproductive Technology (ART) is another valuable therapeutic option regarding pregnancy rates. Thus, the choice between surgical management or ART is still debated. Benefits and risks of these two options should be considered and discussed before planning treatment. In the present study, we aimed to answer the question: Bowel endometriosis and infertility: do we need to operate?
Impact of Laparoscopic Surgical Management of Deep Endometriosis on Pregnancy Rate
2016, Journal of Minimally Invasive Gynecology
Citation Excerpt :
The dilemma regarding how radical the treatment is still ongoing [22]. Although simply removing peritoneal implants restores the peritoneal environment and enhances fertility, others believe an aggressive resection of all residual disease is necessary [15,23–25]. Stepniewska et al [23] reported higher pregnancy rate in patients undergoing complete excision of disease involving the posterior compartment, including bowel resection when required, in comparison with those patients in whom residual disease remained (35 % vs 21%).
To evaluate the impact of laparoscopic excision of lesions on deep endometriosis-related infertility.
Retrospective study.
Endometriosis tertiary referral center (Canadian Task Force II-2).
A group of 115 patients who had undergone laparoscopic surgery for infertility with histologic confirmation of deep endometriosis.
Patient medical records and operative reports were reviewed. Telephone interviews were conducted for long-term follow-up of fertility outcomes.
Evaluation of fertility outcome after laparoscopic treatment of deep endometriosis by spontaneous conception and by assisted reproductive technology (ART) correlated with lesion number, size, and location (anterior, posterolateral, pouch of Douglas, and multiple locations). After a mean follow-up of 22 months the overall pregnancy rate was 54.78% (n = 63) with a live-birth rate of 42.6% (n = 49). Among those patients given the chance to conceive spontaneously (n = 70), the overall pregnancy rate was 60% (n = 42): 38.5% (n = 27) spontaneously and 21.4% (n = 15) by ART. The removal of multiple lesions was associated with a higher pregnancy rate after surgery. When comparing isolated lesion size and disease location, there was no difference in pregnancy rate. Furthermore, those patients who underwent surgical eradication of the disease for the first time had a higher pregnancy rate (odds ratio, 4.18).
This study demonstrates that laparoscopic excision of deep endometriosis enhances pregnancy rate, by both spontaneous conception and ART. First surgical treatment of multiple lesions was associated with higher pregnancy rates, whereas isolated lesions influenced the pregnancy rate irrespective of their location and size.
Treatment of infertility associated with deep endometriosis: Definition of therapeutic balances
2015, Fertility and Sterility
Citation Excerpt :
In this regard, it has to be emphasized that these results are an overestimation of the benefits of surgery and that attributing this rate of success entirely to surgery is problematic (7, 13). In fact, it has been shown that extensive surgery in women with deep and intraperitonal endometriosis, when compared with intraperitonal surgery only, does not modify global fertility outcome (24-month cumulative PR, 25% and 23%, respectively; P = NS) (34). Reasons to recommend extreme caution in the interpretation of results emerging from case series are listed and briefly discussed in Table 1.
Deep endometriosis is a demanding condition that is associated with infertility. However, evidence supporting a direct link between deep endometriosis and infertility is weak. In fact, infertility in affected patients is more likely to be explained by the strong association between deep endometriosis and adhesions, superficial endometriotic implants, ovarian endometriomas, and adenomyosis. The purported beneficial effects of surgery on infertility are mainly based on the 40%–42% pregnancy rate (PR) after surgery observed in published case series. However, this level of evidence is questionable and overestimates the benefits of the intervention. Even if comparative studies are lacking, IVF may be a valid alternative. The procedure may be less effective in affected women compared with other indications and it is not without additional deep endometriosis-related risks. Some case reports suggest that lesions might progress during IVF causing ureteral or intestinal complications or can decidualize during pregnancy causing intestinal perforation, pneumothorax, and pelvic vessels rupture. Finally, in the decision-making process, physicians should also consider that women with a history of deep endometriosis may face an increased risk of pregnancy complications. In conclusion, clear recommendation for the management of infertile women with deep endometriosis cannot be extrapolated from the literature. The therapeutic decision should be based on a comprehensive evaluation that includes clinical history, instrumental findings, pain symptoms, risks of pregnancy complications, and the woman's wishes.

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: The authors do not have any conflicts of interest or financial disclosures.

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Original ArticleInfertile Women with Deep and Intraperitoneal Endometriosis: Comparison of Fertility Outcome According to the Extent of Surgery

Abstract

Study Objective

Design

Setting

Patients

Interventions

Measurements and Main Results

Conclusion

Section snippets

Materials and Methods

Results

Discussion

Conclusion

Fertil Steril

Fertil Steril

Am J Obstet Gynecol

Fertil Steril

Fertil Steril

Fertil Steril

Am J Prev Med

J Am Assoc Gynecol Laparosc

Am J Obstet Gynecol

Fertil Steril

Reprod Biomed Online

J Minim Invasive Gynecol

J Minim Invasive Gynecol

J Am Assoc Gynecol Laparosc

Obstet Gynecol

Fertil Steril

Am J Obstet Gynecol

Original Article
Infertile Women with Deep and Intraperitoneal Endometriosis: Comparison of Fertility Outcome According to the Extent of Surgery