Ovarian Endometrioma Research Articles

Identification of lesional attributes of dysmenorrhea severity and the serum antimüllerian hormone levels in women with ovarian endometriomas

To investigate whether lesional immunostaining of putative biomarkers of recurrence and the extent of lesional and cortical fibroses are correlated with the severity of dysmenorrhea and serum antimüllerian hormone (AMH) levels in women with ovarian endometriomas (OEs). Retrospective cohort study. Academic hospital. A total of 313 women with histologically confirmed OEs were recruited. Their demographic and clinical information and data on their preoperative AMH levels were collected. Additionally, samples of their lesional tissues and ovarian cortex tissues adjacent to the OE lesions were procured for histologic and immunohistochemistry analyses. None. All OE tissue samples were stained for phosphorylated nuclear factor κB p65 subunit, progesterone receptor isoform B, Slit2, and α-smooth muscle actin. In addition, the extent of lesional and cortical fibroses was quantitated by Masson trichrome staining. We evaluated the relationship between the lesion size; laterality; extent of lesional and cortical fibroses, along with the putative markers of recurrence; and severity of dysmenorrhea and preoperative serum AMH levels in patients with OE. We found that the extent of lesional fibrosis was positively correlated with the severity of dysmenorrhea but had no impact on the AMH levels. On the other hand, the extent of cortical fibrosis, along with age, was negatively correlated with the AMH levels. The correlation between lesional fibrosis and the severity of dysmenorrhea and between cortical fibrosis and the AMH levels would call an early intervention once OE is diagnosed or suspected to prevent further pain and diminished ovarian reserve.

AP-1 Subunit JUNB Promotes Invasive Phenotypes in Endometriosis.

Endometriosis is a disease defined by the presence of abnormal endometrium at ectopic sites, causing pain and infertility in 10% of women. Mutations in the chromatin remodeling protein ARID1A (AT-rich interactive domain-containing protein 1A) have been identified in endometriosis, particularly in the more severe deep infiltrating endometriosis and ovarian endometrioma subtypes. ARID1A has been shown to regulate chromatin at binding sites of the Activator Protein 1 (AP-1) transcription factor, and AP-1 expression has been shown in multiple endometriosis models. Here, we describe a role for AP-1 subunit JUNB in promoting invasive phenotypes in endometriosis. Through a series of knockdown experiments in the 12Z endometriosis cell line, we show that JUNB expression in endometriosis promotes the expression of epithelial-to-mesenchymal transition genes co-regulated by ARID1A including transcription factors SNAI1 and SNAI2, cell adhesion molecules ICAM1 and VCAM1, and extracellular matrix remodelers LOX and LOXL2. In highly invasive ARID1A-deficient endometriotic cells, co-knockdown of JUNB is sufficient to suppress invasion. These results suggest that AP-1 plays an important role in the progression of invasive endometriosis, and that therapeutic inhibition of AP-1 could prevent the occurrence of deep infiltrating endometriosis.

Endometriosis and Infertility: A Long-Life Approach to Preserve Reproductive Integrity.

Laparoscopic surgery was originally considered the gold standard in the treatment of endometriosis-related infertility. Assisted reproductive technology (ART) was indicated as second-line treatment or in the case of male factor. The combined approach of surgery followed by ART proved to offer higher chances of pregnancy in infertile women with endometriosis. However, it was highlighted how pelvic surgery for endometriosis, especially in cases of ovarian endometriomas, could cause iatrogenic damage due to ovarian reserve loss, adhesion formation (scarring), and ischemic damage. Furthermore, in the last few years, the trend to delay the first childbirth, recent technological advances in ultrasound diagnosis, and technological progress in clinical and laboratory aspects of ART have certainly influenced the approach to infertility and endometriosis with, ART assuming a more relevant role. Management of endometriosis should take into account that the disease is chronic and involves the reproductive system. Consequently, treatment and counselling should aim to preserve the chances of pregnancy for the patient, even if it is not associated with infertility. This review will analyse the evolution of the management of infertility associated with endometriosis and propose an algorithm for treatment decision-making based on the most recent acquisitions.

The Comparison of Three Predictive Indexes to Discriminate Malignant Ovarian Tumors from Benign Ovarian Endometrioma: The Characteristics and Efficacy.

This study aimed to evaluate the prediction efficacy of malignant transformation of ovarian endometrioma (OE) using the Copenhagen Index (CPH-I), the risk of ovarian malignancy algorithm (ROMA), and the R2 predictive index. This retrospective study was conducted at the Department of Gynecology, Nara Medical University Hospital, from January 2008 to July 2021. A total of 171 patients were included in the study. In the current study, cases were divided into three cohorts: pre-menopausal, post-menopausal, and a combined cohort. Patients with benign ovarian tumor mainly received laparoscopic surgery, and patients with suspected malignant tumors underwent laparotomy. Information from a review chart of the patients’ medical records was collected. In the combined cohort, a multivariate analysis confirmed that the ROMA index, the R2 predictive index, and tumor laterality were extracted as independent factors for predicting malignant tumors (hazard ratio (HR): 222.14, 95% confidence interval (CI): 22.27–2215.50, p < 0.001; HR: 9.80, 95% CI: 2.90–33.13, p < 0.001; HR: 0.15, 95% CI: 0.03–0.75, p = 0.021, respectively). In the pre-menopausal cohort, a multivariate analysis confirmed that the CPH index and the R2 predictive index were extracted as independent factors for predicting malignant tumors (HR: 6.45, 95% CI: 1.47–28.22, p = 0.013; HR: 31.19, 95% CI: 8.48–114.74, p < 0.001, respectively). Moreover, the R2 predictive index was only extracted as an independent factor for predicting borderline tumors (HR: 45.00, 95% CI: 7.43–272.52, p < 0.001) in the combined cohort. In pre-menopausal cases or borderline cases, the R2 predictive index is useful; while, in post-menopausal cases, the ROMA index is better than the other indexes.

Efficacy of ablation and sclerotherapy for the management of ovarian endometrioma: A narrative review.

Ovarian cystectomy is the preferred technique for the surgical management of ovarian endometrioma. However, other techniques such as ablation or sclerotherapy are also commonly used. The aim of this review is to summarize information regarding the efficacy of ablation and sclerotherapy compared to cystectomy in terms of ovarian reserve, the recurrence rate, and the pregnancy rate. Several studies comparing ablation versus cystectomy or sclerotherapy versus cystectomy in terms of the serum anti-Müllerian hormone (AMH) decrement, endometrioma recurrence, or the pregnancy rate were identified and summarized. Both ablation and cystectomy have a negative impact on ovarian reserve, but ablation results in a smaller serum AMH decrement than cystectomy. Nonetheless, the recurrence rate is higher after ablation than after cystectomy. More studies are needed to demonstrate whether the pregnancy rate is different according to whether patients undergo ablation or cystectomy. The evidence remains inconclusive regarding whether sclerotherapy is better than cystectomy in terms of ovarian reserve. The recurrence rates appear to be similar between sclerotherapy and cystectomy. There is not yet concrete evidence that sclerotherapy helps to improve the pregnancy rate via in vitro fertilization in comparison to cystectomy or no sclerotherapy.

Laser Vaporization vs. Cystectomy in Women with Ovarian Endometrioma: A Systematic Review and Meta-analysis [A96

INTRODUCTION: There are still many controversies about managing patients with ovarian endometrioma (OE), discussing recurrence rates, pregnancy rates, and reduction of ovarian reserve (OR). The objective of this study was to compare outcomes after laparoscopic cystectomy versus laser vaporization in women with OE. METHODS: A systematic review and meta-analysis was registered in PROSPERO (CRD42021281781) and was done according to the PRISMA 2020 checklist. Studies (published until October 2021) were identified by searching PubMed, Cochrane Library, Google Scholar, and ClinicalTrials databases (keywords "cystectomy," "laser vaporization," and "endometrioma"). Inclusion criteria: women of reproductive age undergoing surgery for OE larger than 30 mm. Outcomes-risk ratio for recurrence, ovarian reserve, and pregnancy rates. Tools recommended by the Cochrane Society achieved risk of bias assessment. RESULTS: In total, 874 studies were found, and nine studies were included in qualitative synthesis (822 patients). All of the authors compared the efficacy of cystectomy or laser vaporization in reproductive-aged women with OE. Overall risk of bias for randomized trials was 80% “some concerns” and 20% “low,” for cohort studies, 50% “some concerns” and 50% “low.” The primary meta-analysis focused on recurrence rates (four studies included in a meta-analysis) with no statistically significant difference found between these interventions (RR = 0.53, 95%CI: 0.24 to 1.21, P=.13). The next meta-analysis estimated antral follicle count (three studies) which was significantly lower in the cystectomy group (RR=-2.56, 95% CI: -3.71 to -1.42, P&lt;.0001). Pregnancy rates were analyzed in three studies with no statistically significant difference (RR=0.96, 95% CI: 0.81 to 1.14, P=.64). CONCLUSION: There was no statistical difference in recurrence rate and pregnancy rates, butt antral follicle count was higher in the laser vaporization group. Nevertheless, we need more clinical trials for stronger recommendations.

Pharmacological correction of immunometabolic disorders in patients with endometrioma along with chronic inflammatory diseases of the genital tract

The objective: to determine the markers of the inflammatory process, development and implementation of methods for pharmacological correction of immunometabolic disorders in patients with endometrioma on the background of chronic inflammatory processes of the pelvic organs. Materials and methods. A complex clinical and laboratory examination of 90 patients with ovarian endometrioma on the background of chronic inflammation was carried out. Of these patients, the comparison group included 45 patients who received basic therapy (antibacterial drugs cefotaxime and metronidazole, vitamin therapy (B vitamins), combined oral contraceptives with dienogest). Patients in the main group (45 women) received basic anti-inflammatory and antibiotic therapy, together with drugs that improve microcirculation and have systemic and local anti-inflammatory and thrombolytic properties (tissue antihypoxant, deproteinized hemoderivative drug from calf blood and local two-component thrombolytic in suppositories) and dienogest and vitamin D3. The control group included 30 gynecologically healthy women.ELISA-method was used to determine tumor necrosis factor-α (TNF-α) level, interleukins (IL) 1β, 4, 10, interferon-γ in blood serum and cervical mucus, immunoglobulins A, M, G in blood serum, and C-reactive protein (CRP), neopterin and 25-hydroxyvitamin-D3. Results. We determined that in patients with endometrioma on the background of chronic pelvic inflammatory disease at the systemic and local levels there are an increased level of proinflammatory cytokines and decreased level of anti-inflammatory cytokines, as well as increased IFN-γ level, increased CRP – in 8.2 times, and neopterin – 2.7 times (p &lt;0.05) relative to healthy women. The use of the proposed treatment program leads to normalize of IgG level and anti-inflammatory cytokine indices within a month. The level of CRP was significantly reduced in the main group, both in blood serum and cervical mucus. There was a decrease neopterin level in patients of the main group by 1.8 times after the treatment.Conclusions. Additional criteria for diagnosis of the inflammatory process in patients with endometrioma are a significant increase level of pro-inflammatory cytokines (TNF-α, IL-1β) and a decrease level of anti-inflammatory (IL-4, IL-10) cytokines, as well as a significant increase of C-reactive protein and neopterin.Studies suggest that the proposed therapy has a corrective effect on altered parameters of metabolic and immune status, which explains the importance of use in this group of patients the antibacterial therapy together with immunomodulatory, antiviral and metabolic drugs.

Salpingo-oophorectomy or surveillance for ovarian endometrioma in asymptomatic premenopausal women: a cost-effectiveness analysis

The lifetime risk of ovarian cancer is 1.9% among women with endometriosis compared with 1.3% among the general population. When an asymptomatic endometrioma is incidentally discovered on imaging, gynecologists must weigh the procedural complications and the potential for subsequent surgical menopause against future ovarian pathology or cancer. We aimed to determine if performing unilateral salpingo-oophorectomy is a more cost-effective strategy for the prevention of death than surveillance for asymptomatic endometriomas. We created a cost-effectiveness model using TreeAge Pro (TreeAge Software Inc; Williamstown, MA) with a lifetime horizon. Our hypothetical cohort included premenopausal patients with 2 ovaries who did not desire fertility. Those diagnosed with asymptomatic endometrioma underwent either unilateral salpingo-oophorectomy or surveillance (ultrasound 6-12 weeks after diagnosis, then annually). Our primary effectiveness outcome was mortality, including death from ovarian cancer or surgery and all-cause mortality related to surgical menopause (± hormone replacement therapy) if the contralateral ovary is removed. We modeled the probabilities of surgical complications, occult malignancy, development of contralateral adnexal pathology, surgical menopause, use of hormone replacement therapy, and development of ovarian cancer. The costs included surgical procedures, complications, ultrasound surveillance, hormone therapy, and treatment of ovarian cancer, with information gathered from Medicare reimbursement data and published literature. Cost-effectiveness was determined using the incremental cost-effectiveness ratio of Δ costs / Δ deaths with a willingness-to-pay threshold of $11.6 million as the value of a statistical life. Multiple 1-way sensitivity analyses were performed to evaluate model robustness. Our model demonstrated that unilateral salpingo-oophorectomy is associated with improved outcomes compared with surveillance, with fewer deaths (0.28% vs 1.50%) and fewer cases of ovarian cancer (0.42% vs 2.96%). However, it costs more than sonographic surveillance at $6403.43 vs $5381.39 per case of incidental endometrioma. The incremental cost-effectiveness ratio showed that unilateral salpingo-oophorectomy costs $83,773.77 per death prevented and $40,237.80 per case of ovarian cancer prevented. As both values were well below the willingness-to-pay threshold, unilateral salpingo-oophorectomy is cost-effective and is the preferred strategy. If unilateral salpingo-oophorectomy were chosen over surveillance for premenopausal patients with incidental endometriomas, 1 diagnosis of ovarian cancer would be prevented in every 40 patients and 1 death averted in every 82 patients. We performed 1-way sensitivity analyses for all input variables and determined that there were no reasonable inputs that would alter our conclusions. Unilateral salpingo-oophorectomy is cost-effective and is the preferred strategy compared with surveillance for the management of incidental endometrioma in a premenopausal patient not desiring fertility. It incurs fewer deaths and fewer cases of ovarian cancer with costs below the national willingness-to-pay thresholds.

Elevated phosphorylation of estrogen receptor α at serine-118 in ovarian endometrioma

To evaluate the phosphorylation of estrogen receptor α at serine-118 (phospho-ERα S118) in the endometrium, ovarian endometrioma, and deep infiltrating endometriosis (DIE). Experimental study. University-affiliated hospital and academic research laboratory. Twenty-five patients underwent a hysterectomy, 18 patients underwent surgical removal of ovarian endometrioma, and 6 patients underwent DIE. Tissue samples were obtained from patients who underwent surgical procedures. Immunostaining for phospho-ERα S118, ERα, or phosphorylated p44/42 mitogen-activated protein kinase (phospho-p44/42 MAPK) was performed to evaluate the endometrium with or without endometriosis, ovarian endometrioma, and DIE. For invitro analysis, endometrial epithelial cells (Ishikawa cells) were stimulated with estradiol (E2) or tumor necrosis factor alpha (TNFα), and the expression levels of phospho-ERα S118 and phospho-p44/42 MAPK were evaluated via Western blotting. First, phospho-ERα S118 level was significantly higher in the glands and stroma of ovarian endometriosis samples than in those of endometrial and DIE samples. Second, colocalization of phospho-p44/42 MAPK and phospho-ERα S118 was observed in the glands of ovarian endometrioma. The proportions of cells strongly expressing phospho-p44/42 and phospho-ERα were 87% in phosphor-p44/42 MAPK-positive cells and 79% in phosphor-ERα-positive cells. Third, E2 stimulation significantly enhanced phospho-ERα S118 after 15 and 30 minutes in invitro analysis using endometrial epithelial cells. Fourth, TNFα stimulation modestly but significantly enhanced phospho-ERα S118 after 15 and 30 minutes. Fifth, in Ishikawa cells, treatment with a p44/42 inhibitor (PD98059) significantly reduced phospho-ERα S118 by TNFα but not by E2. ERα-S118 phosphorylation was increased in ovarian endometriosis. Our findings may provide a new perspective for understanding the mechanism of increased ERα action in the pathophysiology of endometriosis.

Downregulating HK2 inhibits proliferation of endometrial stromal cells through a noncanonical pathway involving phosphorylation of signal transducer and activator of transcription 1 in endometriosis.

Endometriosis is a benign gynecologic disease that causes chronic pelvic pain, dysmenorrhea and infertility and shares several characteristics with malignant tumors, afflicting women of reproductive age. Hexokinase 2 plays an essential role as the first rate-limiting enzyme in the metabolic glycolysis pathway, and its abnormal elevation in tumors is associated with tumor genesis and metastasis. However, the expression and role of hexokinase 2 in endometriosis remain unclear. We sequenced the primary endometrial stromal cells from patients with endometrioma and utilized immunohistochemistry, quantitative real-time PCR, and western blot to determine the expression of hexokinase 2. Then wound healing assays, cell invasion assays, and cell proliferation assays were performed to explore the functions of hexokinase 2 in endometrial stromal cells. Furthermore, mice models of endometriosis were used to observe the effects of hexokinase 2 inhibitors in vivo. Lastly, glycolysis metabolism detection and transcriptome sequencing were carried out in hexokinase 2-knockdown endometrial stromal cells to analyze the mechanism of hexokinase 2 affecting cell function. Endometrial stromal cells of endometrioma displayed active glycolysis metabolism and elevated expression of hexokinase 2. Downregulating hexokinase 2 reduced the migration, invasion, and proliferation capacity of endometrial stromal cells. Knockdown of hexokinase 2 induced upregulation of signal transducer and activator of transcription 1 and their phosphorylation to attenuate the proliferation of endometrial stromal cells. Hexokinase 2 is associated with the migration, invasion, and proliferation of endometrial stromal cells, which might provide new insights into the pathogenesis and treatment of endometriosis. HK2 is upregulated in ovarian endometrioma and knockdown of HK2 induced upregulation of signal transducer and activator of transcription 1 (STAT1) and their phosphorylation to attenuate the proliferation of endometrial stromal cells.

Comparison of the Effect on the Ovarian Reserve of Modern Methods of Treatment of Endometrioid Cysts

ObjectiveTo compare the efficacy and safety of autologous platelet-rich plasma (PRP) therapy in laparoscopy and transvaginal sclerotherapy for the treatment of endometrioid cysts for maintaining ovarian reserve. MethodsThe study included 71 women under age 35 years with primary and secondary infertility. Twenty women underwent sclerotherapy of endometrioid cysts followed by autologous PRP injection into ovarian tissue, and 21 underwent laparoscopic cyst removal by stripping followed by autologous PRP injection. The control group consisted of 30 women who underwent laparoscopic cystectomy by stripping without autologous PRP injection. We assessed ovarian reserve for all patients before surgery as well 3 and 6 months after surgery by measuring serum anti-Müllerian hormone (AMH) levels and calculating antral follicle count using ultrasound. ResultsIn the control group, AMH levels had decreased significantly at 3 and 6 months post-surgery, whereas levels in laparoscopy and PRP group remained almost unchanged from initial levels. In the sclerotherapy group, we observed a tendency towards increased AMH levels, but it was not statistically significant when compared with initial results. Follicle count changes were similar to AMH patterns. ConclusionIn this study, sclerotherapy in combination with PRP therapy for ovarian endometriomas was associated with improved measures of ovarian reserve, and the combination of laparoscopic excision of the endometrioma with PRP therapy facilitated ovarian reserve preservation.

Does current ovarian endometrioma increase the time for DOR patients to reach live birth in IVF?

BackgroundThe contents of ovarian endometrioma (OMA) such as inflammatory mediators, reactive oxygen species, and iron may disrupt normal folliculogenesis and result in subsequent oocyte apoptosis. Therefore, women with OMA have a potential risk of diminished ovarian reserve (DOR). The purpose of this study is to compare the in vitro fertilization (IVF) outcomes and efficiency between DOR patients with and without current OMA.MethodsThis retrospective case-control study included a total of 493 women with DOR (serum anti-Müllerian hormone level < 1.1 ng/mL). Ninety patients with OMA (Group A) underwent 191 IVF cycles and 403 patients without ovarian OMA (Group B) underwent 888 IVF cycles in our center between January 2014 and December 2018. Basal characteristics and IVF outcomes were compared between Group A and Group B. Time to achieve live birth were compared between patients with live birth in two groups (Group A1, 31 patients; Group B1, 132 patients).ResultsClinical and demographic characteristics of patients were similar respectively between groups (A vs. B, A1 vs. B1). There were no statistically significant differences in implantation rate, live birth rate per OPU and per ET cycle and the cumulative live birth rate per patient and per patient with good-quality embryos between Group A and Group B (P > 0.05). Total time to achieve live birth has no statistically significant difference between Group A1 and Group B1 (P > 0.05).ConclusionFor DOR women, presence of endometrioma did not affect the IVF outcomes. Even the time to get live birth was not prolonged by current OMA.

Pelvic pain and psycho­emotional status in women with ovarian endometrioma combined with pelvic inflammatory diseases: treatment options choice

The connection between chronic pelvic pain and the presence in the body of a pathological source of structural and morphological changes in tissue, e.g. in connection with uterine fibroids, endometriosis, chronic inflammatory processes of the pelvic organs remains a traditional opinion. Endometriosis, which is characterized by a chronic pelvic pain, affects about 10% of women of reproductive age, and the problem of studying of endometrioid cysts demonstrates its relevance by dominating in the structure of genital endometriosis up to 59%. Chronic pelvic pain causes inappropriate courses of antibacterial therapy and, as a consequence, dysbiosis, the development of ovarian insufficiency syndrome, and the surgical approach does not always show the desired results, often worsening the clinical picture and psycho-emotional status of the patient. The objective: of this study was to assess the severity of the pain syndrome and psychological status in patients with pelvic pain associated with ovarian endometrioma and to seek effective therapeutic options. Materials and methods. The study included 40 patients with ovarian endometriosis combined with pelvic inflammatory disease (main group) and 40 patients with isolated endometrioma (comparison group). The control group consisted of 30 patients without manifestations of genital endometriosis. Analysis of somatic and gynecological anamnesis was used, as well as the objective and gynecological examination, data from adapted Beck’s Depression Inventory and State-Trait Anxiety Inventory, pain assessment according to the visual-analog scale (VAS), sonographic examination of the pelvic organs, evaluation of magnetic resonance imaging, endoscopic and histological methods of examination. Results. Dyspareunia was noted in one third of patients of the main group; dysuric manifestations, intestinal disorders in one in four women, a combination with manifestations of asthenic-neurotic syndrome in a third of women, the intensity of pain was presented in a third as severe and unbearable. It should be noted that the percentage of secondary infertility increased by 2.6 times, in two thirds of cases there were menstrual disorders, which were dominated by manifestations of algodysmenorrhea and abnormal uterine bleeding. The analysis of psychological questionnaires noted equal percentage of moderate and mild depressive symptoms in the main group, as well as, along with a decrease in psychological and emotional adaptation, high rates of situational and personal anxiety. Proposed therapeutic options included the use of dienogest primarily in women with mild to moderate pain syndrome, the possibility of long-term use at risk of recurrence and taking into account the smaller percentage of probable side effects. Conclusions. The analysis of the obtained data allowed to indicate to more intense pain syndrome, high frequency of menstrual disorders, secondary infertility and manifestations of nonspecific clinical symptoms in patients with endometriomas combined with the pelvic inflammatory processes. The psycho-emotional state of women is characterized by high levels of depressive and anxiety disorders, as well as a pronounced intensity of pain syndrome in one third of cases. At weak and moderate degree of pelvic pain the drug of choice of the therapeutic program is dienogest, the use of which is expedient in the long run, in case of the expressed intensity of a pain syndrome it is expedient to give a preference to the gonadotropin-releasing hormone agonist.

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.

Impact of Surgical Management of Endometrioma on Ovarian Reserve

Objective: The aim of this study was to explore the outcome of surgical removal of endometriotic cyst on ovarian reserve.&#x0D; Materials and methods: This prospective observational study was carried out in Infertility Care and Research Centre, Dhaka, Bangladesh between January 2011 and December 2018. One hundred and fifty-five patients, who had an ultrasonographic diagnosis of endometrioma measuring ³3 cm and underwent surgical excision due to subfertility were the candidates for this study. The exclusion criteria were a) previous ovarian cystectomy, b) removal of one ovary, c) irregular menstrual cycle, d) polycystic ovarian syndrome e) endocrine disorder, f) low AMH (&lt;1ng/ml), g) history of taking medication for endometriosis that could affect ovarian function, e.g., GnRH analogues or oral contraceptives during the 6 months preceding scheduled surgery. To investigate the effect of surgery on ovarian reserve, their FSH, E2 and AMH were measured before and after surgery. Tests were done before surgery and repeated after 3 months and 6 months of surgery. A value of &lt; 0.05 was considered significant.&#x0D; Results: Mean age of the patients was 31.72 ±2.77 years. The baseline FSH, E2 and AMH were within normal limit. In 63.88% of the cases the cysts were unilateral and 83.22% of the cases the size of the cysts were within 10 cm. To assess the change of ovarian reserve FSH, E2 and AMH were measured in 3 and 6 months after surgery. There was marked declining of AMH level from baseline to both 3 months and 6 months after surgery p is &lt;0.0001. There was no significant change of FSH and AMH between 3 months and 6 months after surgery.&#x0D; Conclusion: Cystectomy in ovarian endometrioma significantly reduces ovarian reserve, which is menifested by reduced level of AMH.&#x0D; Bangladesh J Obstet Gynaecol, 2020; Vol. 35(2): 96-101

BDNF and TrKB expression levels in patients with endometriosis and their associations with dysmenorrhoea

BackgroundBrain-derived neurotrophic factor (BDNF) is a known regulator of the development and maintenance of chronic pain in various chronic disorders. Together with its high-affinity tyrosine kinase type B (TrKB) receptor, BDNF is extensively expressed in the mammalian female reproductive system. However, BDNF and TrKB expression in different stages of endometriosis and the relationship between the expression of each in ectopic lesions and endometriosis pain remain unclear.MethodsSixty-two women who underwent laparoscopic surgery were enrolled in this study: forty-six diagnosed with ovarian endometrioma (study group) and sixteen diagnosed with ovarian benign tumours (control group). Samples from eutopic endometrium and ovarian endometriotic lesions were obtained at laparoscopic surgery. BDNF and TrKB messenger RNA (mRNA) and proteins levels in the eutopic and ectopic endometrium of both groups were measured by real-time PCR and immunohistochemical staining, respectively. Before the surgery the visual analogue scale (VAS) was used to measure dysmenorrhoea.ResultsBDNF and TrKB expression levels were higher in ovarian endometriotic lesions than in eutopic endometrium and normal endometrium (P < 0.05), and there was no cyclical change. Furthermore, their expression levels were higher in eutopic endometrium than in normal endometrium (P < 0.05), and BDNF and TrKB levels were higher in stage IV ovarian endometriotic lesions than in stage II and III lesions (P < 0.05), with their expression being non-significantly higher in stage III than in stage II (P > 0.05). Additionally, correlation coefficients for the association analysis between the mRNA expression of BDNF or TrKB in eutopic endometrium and the dysmenorrhoea VAS score were r = 0.52 and r = 0.56 for BDNF and TrKB, respectively (P < 0.05). The correlation coefficients for the associations between BDNF and TrKB in both the eutopic and ectopic endometrium were r = 0.82 and r = 0.66, respectively (P < 0.05).ConclusionsBDNF and TrKB are closely related to dysmenorrhoea caused by endometriosis and may be important in the pathobiology or pathophysiology of endometriosis.

Decidualized ovarian endometrioma mimicking malignancy in pregnancy: a case report and literature review

BackgroundOvarian endometrioma is a common gynecologic disease among reproductive-aged women. Pregnancy-related hormonal status may lead to changes of decidualization, which may resemble ovarian malignancies in sonographic appearance. Here we present a case of decidualized ovarian endometrioma clinically mimicking malignant transformation.Case presentationA 37-year-old pregnant woman presented to our hospital at 25 + 5 weeks of gestation with a persistent left adnexal mass that was first detected on routine ultrasound in the first trimester. Transvaginal and transabdominal ultrasound showed a cystic mass of size 8.4 × 5.8 cm in the left ovary with abundant blood flow signals in the papillary medium echo of the capsule wall and inner wall, raising concern for malignant ovarian tumor. After a multidisciplinary discussion, the patient underwent laparoscopic left salpingo-oophorectomy. The results of the frozen section revealed decidualized endometrioma and the final histopathology confirmed endometrioma with extensive decidualization. The patient’s postoperative recovery was uneventful and she was discharged on the 4th postoperative day.ConclusionsDecidualized ovarian endometrioma is rare. Sonography and magnetic resonance imaging are helpful for differential diagnosis. Conservative management of expectant management and serial monitoring should be adopted if decidualized endometriosis is suspected.

Progesterone Receptor Status of Epithelial Cells as a Predictive Marker for Postoperative Recurrence of Endometriosis.

Progesterone resistance including progesterone receptor (PR) deficiency contributes to the pathophysiology of endometriosis; however, whether the PR expression levels in ovarian endometrioma (OE) correlate with the postoperative recurrence of endometriosis remains unclear. This study aimed to investigate the association between PR expression levels in OE and the recurrence of endometriosis. OE specimens were obtained from 132 patients who underwent conservative surgery for endometriosis. The PR expression levels were evaluated using the H score after immunohistochemical staining. Of the 132 patients, 36 (27.3%) experienced recurrence and 96 (72.7%) did not. No differences were observed in the patient characteristics between the recurrence and nonrecurrence groups except for follow-up period. PR immunoreactivity in the epithelial cells (ECs) was statistically significantly lower in the recurrent group than in the nonrecurrent group (P < .01); however, this change was not observed in the stromal cells. Moreover, multivariable logistic regression analysis revealed that the H score of PR in ECs was an independent factor and was statistically significantly associated with the recurrence of endometriosis (P = .01). Furthermore, we divided the patients into PR-negative or PR-positive groups. The cumulative recurrence rate in the negative PR group was statistically significantly higher than that in the positive PR group (P = .046). Low PR expression levels in OE-ECs may predict the recurrence of endometriosis. The PR status in OE-ECs is associated with the pathophysiology of the recurrence of endometriosis, and optimized postoperative management for endometriosis may be provided by referring to the PR status.

Prevalence of endometriosis and adenomyosis at transvaginal ultrasound examination in symptomatic women.

Prevalence of endometriosis is commonly reported based on surgery findings and varies widely depending on study population and indication for surgery. Symptoms such as dysmenorrhea, pelvic pain, dyspareunia, dysuria, and dyschezia can be associated with endometriosis and adenomyosis. Transvaginal ultrasound examination is proposed to be the first-line diagnostic method, nevertheless there are no published ultrasound-based studies reporting prevalence of endometriosis and adenomyosis in symptomatic women other than those scheduled for surgery. The aim of this study was to determine the prevalence of endometriosis and adenomyosis as assessed by transvaginal ultrasound in women with symptoms suggestive of endometriosis and adenomyosis. This is a retrospective cross-sectional study performed at a tertiary-care center including 373 symptomatic women who were systematically examined with transvaginal ultrasound by an experienced ultrasound examiner. Before ultrasound examination women filled in a questionnaire including self-assessment of the severity of their symptoms (dysmenorrhea, chronic pelvic pain, dyspareunia, dysuria, dyschezia) using a visual analog scale. Abnormal findings in the uterus, ovaries, bowel, urinary bladder, uterosacral ligaments, and rectovaginal septum were noted, and their size and location were described. Prevalence of endometriosis, adenomyosis, endometrioma, and deep endometriosis in different anatomical locations was reported. Prevalence of ovarian endometrioma and/or deep endometriosis was 25% and of adenomyosis was 12%. Prevalence of endometrioma was 20% and of deep endometriosis was 9%, for each location being 8% in the bowel, 3% in the uterosacral ligaments, 3% in the rectovaginal septum and 0.5% in the urinary bladder. In symptomatic women examined with transvaginal ultrasound by an experienced ultrasound examiner, ovarian endometrioma and/or deep endometriosis was found in one of four women and adenomyosis in one of nine women. Deep endometriosis was present in one of 11 women. Despite having symptoms, half of the women had no abnormal ultrasound findings.

Salpingo-oophorectomy or surveillance for ovarian endometrioma in asymptomatic premenopausal women?: a cost-effectiveness analysis

The lifetime risk of ovarian cancer is 1.9% among women with endometriosis compared to 1.3% among the general population. When an asymptomatic endometrioma is incidentally discovered on imaging, gynecologists must weigh procedural complications and surgical menopause against future ovarian pathology or cancer. We aimed to determine if performing unilateral salpingo-oophorectomy (USO) is a cost-effective strategy for prevention of death compared to surveillance for asymptomatic endometriomas. We created a cost-effectiveness model using TreeAge Pro with a lifetime time horizon. Our hypothetical cohort included premenopausal patients with two ovaries who do not desire fertility. Those diagnosed with asymptomatic endometrioma underwent USO or surveillance (ultrasound 6-12 weeks after diagnosis, then annually). Our primary effectiveness outcome was mortality, including death from ovarian cancer or surgery and all-cause mortality related to surgical menopause (+/- hormone replacement therapy). We modeled the probabilities of surgical complications, occult malignancy, development of contralateral adnexal pathology, surgical menopause, use of hormone replacement therapy, and development of ovarian cancer. Costs included surgical procedures, complications, ultrasound surveillance, hormone therapy, and treatment of ovarian cancer, with information gathered from Medicare reimbursement data and published literature. Cost-effectiveness was determined using the incremental cost-effectiveness ratio (ICER) of Δ costs / Δ deaths with a willingness to pay (WTP) of $11.6 million as the value of a statistical life. Multiple one-way sensitivity analyses were performed to evaluate model robustness. Our model demonstrated that USO costs more than surveillance ($6,403.43 vs. $5,381.39 per case of incidental endometrioma). However, USO improved outcomes with fewer deaths (0.28% vs.1.50%) and fewer cases of ovarian cancer (0.42% vs. 2.96%) than surveillance. The ICER revealed that USO costs $83,773.77 per death prevented and $40,280.46 per case of ovarian cancer prevented compared to surveillance. As both values were well below the WTP threshold, USO is cost-effective and the preferred strategy. If USO were chosen over surveillance for premenopausal patients with incidental endometriomas, one diagnosis of ovarian cancer would be prevented in every 40 patients and one death averted in every 82 patients. We performed one-way sensitivity analyses for all input variables and determined that there were no reasonable inputs that would alter our conclusions. USO is cost-effective and the preferred strategy compared to surveillance for the management of incidental endometrioma in a premenopausal patient not desiring fertility. USO incurs fewer deaths and fewer cases of ovarian cancer with costs below national willingness to pay thresholds.