Previous Surgery For Endometriosis Research Articles

Fertility in patients with untreated colorectal endometriosis

Fertility in patients with untreated colorectal endometriosis

Endometriosis-related infertility: ovarian endometrioma per se is not associated with presentation for infertility.

Is there an association between the endometriosis phenotype and presentation with infertility? In a population of operated patients with histologically proven endometriosis, ovarian endometrioma (OMA) per se is not associated with an increased risk of presentation with infertility, while previous surgery for endometriosis was identified as a risk factor for infertility. The increased prevalence of endometriosis among subfertile women indicates that endometriosis impairs reproduction for reasons that are not completely understood. This was an observational, cross-sectional study using data prospectively collected in all non-pregnant patients aged between 18 and 42 years, who were surgically explored for benign gynaecological conditions at our institution between January 2004 and March 2013. For each patient, a standardized questionnaire was completed during a face-to-face interview conducted by the surgeon during the month preceding surgery. Surgery was performed in 2208 patients, of which 2066 signed their informed consent. Of the 1059 women with a visual diagnosis of endometriosis, 870 had histologically proven endometriosis and complete treatment for their endometriotic lesions, including 307 who presented with infertility. Univariate analysis and multiple logistic regression analysis were performed to determine factors associated with infertility. The following variables were identified as risk factors for endometriosis-related infertility: age >32 years (odds ratio [OR] = 1.9; 95% confidence interval [CI]: 1.4-2.4), previous surgery for endometriosis (OR = 1.9; 95% CI: 1.3-2.2), as well as peritoneal superficial endometriosis (OR = 3.1; 95% CI: 1.9-4.9); Conversely, previous pregnancy was associated with a lower rate of infertility (OR = 0.7; 95% CI: 0.6-0.9 and OR=0.6; 95% CI: 0.4-0.9, respectively). OMA is not selected as a significant risk factor for infertility. The selection of our study population was based on a surgical diagnosis. We cannot exclude that infertile women with OMA associated with a diminished ovarian reserve, as assessed during their infertility work-up, were referred less frequently to surgery and might therefore be underrepresented. In addition we cannot exclude that our group of infertile women present associated other causes of infertility. Identification of risk and preventive factors of endometriosis-related infertility can help improve clinical and surgical management of endometriosis in the setting of infertility. None. None.

Radical Surgery for Endometriosis: Analysis of Quality of Life and Surgical Procedure.

OBJECTIVEThe main aim of this study is to determine the improvement in quality of life in patients who have undergone radical surgery because of severe endometriosis.PATIENTS AND METHODSThis nonrandomized interventional study (quasi experimental) was carried out between January 2009 and September 2014. A total of 46 patients with diagnosis of severe endometriosis were included. Radical surgery, including hysterectomy, was performed. Acting as their own control group, the patients were asked to fill in a validated questionnaire of quality of life [Endometriosis Health Profile-5 (EHP-5)] and a visual analog scale of pain at the moment of the preoperative visit (one month prior to surgery) and six months after the surgery.RESULTSRadical surgery for endometriosis was performed in 46 patients at our center over the period of six years. Among the patients, 73.9% of them had undergone previous surgery for endometriosis. In 82.6% of cases, a complete laparoscopic resection was carried out. Gastrointestinal tract resection was performed in 21.7%, and urinary tract resection was necessary in 8.7%. The mean age of the patients was 38.6 years. The rate of complications was 30.4%. Six months after the surgery, all items of the EHP-5 questionnaire had a lower score, which means an improvement in all aspects of quality of life related to endometriosis. The difference obtained between the scores before and after the surgery was statistically significant. The mean visual analog scale score before the surgery was 8.5, whereas it decreased to 1.4 after the surgery (P < 0.001).CONCLUSIONPerforming a radical surgery is a difficult decision to make; however, it can provide optimal results in terms of improvement of quality of life and, therefore, should be considered when conservative therapy fails.

Impact of osteopathic manipulative therapy on quality of life of patients with deep infiltrating endometriosis with colorectal involvement: results of a pilot study

ObjectiveA prospective pilot study to evaluate the potential role of osteopathic manipulative therapy (OMT) on quality of life (QOL) of patients with Deep Infiltrating Endometriosis (DIE) and colorectal involvement. Study designTwenty patients with DIE and colorectal infiltration completed the SF-36 QOL questionnaire before and after undergoing OMT. ResultsThe median age (range) of the patients was 30.4 years (22–39). Thirty-five percent of the patients had undergone previous surgery for endometriosis and 70% were on medical treatment. Fifteen of the 20 patients (75%) completed the protocol. There was no difference in the epidemiological characteristics or in the pre-OMT Physical Component Summary (PCS) and Mental Component Summary (MCS) of the SF-36 questionnaire between patients who completed the protocol or not. After a mean period of 24 days (15–53), a significant improvement in PCS (p=0.03) and MCS (p=0.0009) compared to pre-OMT values was observed giving a success rate of 80% and 60% in intention-to-treat, respectively. ConclusionOur results support that OMT can improve QOL of patients with DIE and colorectal involvement. Moreover, this pilot study can serve to determine power calculations for future randomized trials.

Ultrasound-Guided Aspiration and Ethanol Sclerotherapy (EST) for Treatment of Cyst Recurrence in Patients after Previous Endometriosis Surgery: Analysis of Influencing Factors Using a Decision Tree

Study ObjectiveTo evaluate the efficiency of transvaginal aspiration accompanied by ethanol sclerotherapy for treating cyst recurrence in patients who have previously undergone surgery to treat endometriosis and to analyze various factors that influence success rates using a data mining system. DesignRetrospective cohort study (Canadian Task Force classification II-3). SettingTeaching hospital affiliated with Chang Gung University, Taoyuan, Taiwan. PatientsOne hundred ninety-six patients with endometrioma recurrence. InterventionA total of 274 transvaginal aspirations followed by sclerotherapy with 95% ethanol. Treatment times varied from immediate removal (0–10 minutes) to in situ retention. Patients were followed up at 3, 6, and 12 months to detect complications, determine the size and persistence of cysts, obtain the pelvic pain score, and assess for pregnancy or the need for repeat surgical intervention. A decision tree was used to determine factors from the collected data that most influenced the success of treatment. Measurements and Main ResultsCyst size was consistently reduced until 6 months after ethanol sclerotherapy. The mean (SD) cyst reduction rate was 37.2% (42.2%), and the pain score reduction rate was 20.5% (71.5%). The antral follicle count was simultaneously increased by 36.4%. Sixty-three patients (23%) required repeated surgery during the observation period and were treated with either repeat aspiration (13.5%) or major laparoscopic or open laparotomic interventions (8.4%). Eighteen of 101 infertile patients (17.8%) achieved pregnancy. The total recovery rate (pregnancy or no persistence of symptoms or cyst) was significantly higher in patients in the groups that received longer treatment (7–10 minutes and retention) than in the groups with shorter treatment (0–6 minute) (47.0% vs 28.7%; p < .005). The highest recovery rate was observed in patients with longer treatment time, smaller cysts (≤5.05 cm), lower CA 125 level (≤62.03 IU/mL), and fewer cysts (≤3 cm) (35 of 49 [71.4%]). In patients with larger cysts and cysts with clear contents, better success can be achieved with longer treatment. The use of postoperative ovarian suppression, traditional Chinese medicine, or no therapy for 6 months before the study was not significant among groups. ConclusionUltrasound-guided sclerotherapy with 95% ethanol retention is an effective alternative therapy for recurrent ovarian endometrioma, in particular in selected patient groups.

Risk Factors for Ectopic Pregnancy After In Vitro Fertilization Treatment

ObjectiveTo identify risk factors for ectopic pregnancy after in vitro fertilization treatment. MethodsWe conducted a study among women who conceived after IVF treatment and evaluated the possible risk factors for ectopic pregnancy. The parameters evaluated were demographics of the patients, cause of infertility, and risk factors for ectopic pregnancy, including tubal infertility and previous ectopic pregnancy. ResultsOf 365 women, 18 women had an ectopic pregnancy and 347 others had an intrauterine pregnancy (control group). The incidence of IVF ectopic pregnancy was 4.9%. The mean age was 34.2±1.4years in the ectopic group and 34.3±0.2years in the control group; mean BMI was 23.8±1.0 in the ectopic group and 24.5±0.9 in the control group. Previous ectopic pregnancy, previous IVF ectopic pregnancy, or smoking did not affect the occurrence of ectopic pregnancy in this population. Logistic regression analysis demonstrated that tubal factor infertility and previous surgery for endometriosis were risk factors for IVF ectopic pregnancy. ConclusionsTubal factor infertility and previous surgery for endometriosis appear to be risk factors for ectopic pregnancy after IVF treatment. Other factors that usually contribute to spontaneous ectopic pregnancy, including previous ectopic pregnancy, pelvic infection, and smoking, were not risk factors for IVF ectopic pregnancy in our study.

Laparoscopic Management of Deep Infiltrating Endometriosis: Our Experience in 3 Years of a Multidisciplinary Group

Study Objective: To evaluate our results in laparoscopic management of deep infiltrating endometriosis. Design: Descriptive study including 52 patients diagnosed of deep infiltrating endometriosis during the last 3 years. Diagnosis was made by clinical exam, transvaginal sonography, MRI, rectosigmoidoscopy, barium enema and cystoscopy. Disease severity was evaluated using Adamyan classification. Setting: Multidisciplinary Endometriosis Unit of Hospital 12 de Octubre (Madrid, Spain). Patients: 52 patients diagnosed of deep infiltrating endometriosis. Intervention: Deep infiltrating endometriosis of posterior compartiment was excised in 76.9%. In 6 patients a bladder nodule was excised and in two cases a partial ureteral resection and re-implantation was done. A nephrectomy was performed in one patient. We performed hysterectomy with bilateral adnexectomy in 5 patients and simple hysterectomy in another. In 17.3% we performed a segmental bowel resection followed by end-to-end anastomosis and shaving in 13.4%. Measurements and Main Results: Mean age was 33.9 years. 41.2% had previous surgery for endometriosis. Most frequent symptoms were dysmenorrhea (88.4%), dyspareunia (65.3%) and dyschesia (53.8%). Sterility was suffered by 17.6%. 2 patients presented intestinal occlusion, 5 hydronephrosis, 5 rectal bleeding and 5 dysuria. Laparoscopic approach was performed in 92.2%. Laparoconversion occurred in 7′8% Mean operating time was 238 minutes (range 90-600). No intraoperative complications were noted. A patient required re-intervention because of anastomosis leakage. Average hospital stay was 5.2 days. During the long term follow up, 84.3% referred significant reductions in preoperative symptoms. Conclusion: Multidisciplinary diagnostic and therapeutic approach (including general surgeons, urologists and radiologists) is essential in deep infiltrating endometriosis context, due to complexity and wide organic affectation of this clinical entity. Surgical treatment is still the best treatment option.

Diagnostic accuracy and potential limitations of transvaginal sonography for bladder endometriosis

To evaluate the accuracy and the potential limitations of transvaginal sonography (TVS) in the preoperative evaluation of women with clinically suspected bladder endometriosis and to describe the sonographic features of the pathological condition in cases in which it was confirmed. In the period between 2001 and 2006, we operated on 490 patients with clinically/sonographically suspected endometriosis. In 41 cases, bladder endometriosis was diagnosed at surgery and confirmed at histopathological examination. All patients underwent TVS in a standardized manner not more than 1 month before surgery. Findings at preoperative TVS were described and compared with those at laparoscopy in order to evaluate the sensitivity, specificity, and positive and negative predictive values of TVS. Bladder endometriosis was correctly identified at TVS in 18/41 cases (43.9%) while 23/41 (56.1%) patients had a negative preoperative sonogram. The sensitivity, specificity and positive and negative predictive values of TVS for bladder endometriosis were 44% (18/41), 100% (449/449), 100% (18/18) and 95% (449/472), respectively, and the total accuracy was 95% (467/490). The detection rate was strongly related to mean lesion diameter as measured by the pathologist (mean +/- SD, 42.5 +/- 22.1 mm in the nodules detected vs. 28.9 +/- 14.8 mm in the nodules missed; P = 0.029) and to a history of previous surgery for endometriosis (70.6% vs. 25.0%; P = 0.005). At TVS, the nodule was hypoechogenic, its morphology was either elongated ('comma-shaped': 12/18, 66.7%) or spherical (6/18, 33.3%), and the site involved was the dome (11/18, 61.1%) or the base (7/18, 38.9%) of the bladder. Small anechogenic cystic areas within the nodule were seen in five of the 18 patients (27.8%) and a bright hyperechogenic rim was seen in 10 (55.6%). The detection rate of bladder endometriosis by TVS depends on the size of the endometriotic nodules, with detected nodules being larger than those that were missed. A history of previous surgery for endometriosis increases the likelihood of bladder endometriosis being detected on ultrasound examination.

Rectovaginal Endometriosis–Characteristics of Operative Treatment and Factors Predicting Bowel Resection

Study Objective The purpose of this study was to characterize operative treatment of patients with rectovaginal endometriosis (RVE), with special emphasis on factors predicting bowel resection. Design A total of 153 symptomatic cases undergoing radical resection of RVE at our institution between January 2000 and May 2004 were reviewed. Univariable and multivariable association models were used in connection with various factors associated with bowel resection. Setting Tertiary referral center. Measurements and Main Results In all, 57 (37%) patients were treated laparoscopically, and 96 (63%) patients via laparotomy. Gastrointestinal and/or urologic surgeon was present in 30% of cases. A total of 54 (35%) patients underwent bowel resection. The median (range) operating times were 145 (75–315) minutes and 100 (20–300) minutes for patients with and without bowel resection, respectively (p <.0001). Four (2.6%) major complications occurred. In the univariable association model, the risk of bowel resection was increased among patients with previous surgery for endometriosis (OR 2.74, 95% CI 1.35–5.54), intestinal symptoms (OR 2.55, 95% CI 1.29–5.02), and revised American Fertility Society score IV (OR 4.71, 95% CI 2.06–10.78). Preoperative use of combined oral contraceptives was associated with a lower risk of bowel resection (OR 0.32, 95% CI 0.15–0.66). Conclusion Operative treatment of RVE is demanding; a multidisciplinary approach is often needed. Patients with intestinal symptoms and those with a history of endometriosis surgery are at increased risk of bowel resection.

Pentoxifylline After Conservative Surgery for Endometriosis: A Randomized, Controlled Trial

Study Objective To compare outcomes after conservative surgery for endometriosis with and without pentoxifylline and to assess the efficacy of pentoxifylline in preventing recurrence of endometriosis after conservative surgery. Design Parallel-group, randomized, controlled trial (Canadian Task Force classification I). Setting Tertiary care hospital. Patients Women undergoing conservative surgery for endometriosis. Interventions Laparoscopic conservative surgery for endometriosis was completed by a single surgeon (J.A.T.), and all suspected endometriotic lesions were widely excised using monopolar coagulation and scissors. All specimens were submitted to pathology for confirmation of the diagnosis. Randomization to the treatment or control groups was completed preoperatively in the outpatient surgery unit by drawing colored marbles. A preoperative visual analog pain scale (VAS) was completed. After surgery, patients were discharged home with prescriptions for naproxen, hydromorphone, and pentoxifylline. Measurements and Main Results Visual analog scale scoring was completed monthly by each patient, and each patient was seen monthly for review and pelvic examination. Analgesic use was recorded daily using an individual medication log. Ongoing treatment choice after completion of the 3-month follow-up was recorded. The relationship between the group receiving pentoxifylline and the control group as well as analysis of the VAS scores at time of surgery and 1, 2, and 3 months postoperatively was determined using a covariate mixed-model ANOVA. Forty-nine patients were enrolled in the trial. One patient became pregnant before surgery, and 1 patient’s chart was not available for analysis. Of the 47 who underwent conservative surgery for endometriosis, 9 (19%) had no endometriosis noted in the pathology specimens submitted. Two patients withdrew from the trial after surgery, and 2 patients were lost to follow-up after relocating to a different city. Nineteen women completed the 3-month follow-up in the control group, 15 in the group receiving pentoxifylline. The mean age, gravidity, parity, body mass index, previous surgery for endometriosis, menstrual cycle, and preoperative analgesic use did not differ significantly between the control and treatment groups. The time to complete the conservative surgery did not vary between the 2 groups. There were no intraoperative complications: two patients were admitted postoperatively, one for nausea and vomiting, one for pain that resolved 24 hours after admission. The VAS scores did not differ at the time of surgery; and in both the control and the pentoxifylline groups, there was significant improvement at each monthly interval (p <.05). The patients receiving pentoxifylline had significantly better VAS scores at 2 and 3 months after surgery (p <.03). Conclusions The use of pentoxifylline after conservative surgery for endometriosis resulted in improved VAS scores at 2 and 3 months after the procedure when compared with patients having conservative surgery only. The longer-term use of pentoxifylline after conservative surgery may improve long-term outcomes after surgical treatment for endometriosis.

Presurgical diagnosis of posterior deep infiltrating endometriosis based on a standardized questionnaire

To derive a diagnostic model based on symptoms and history as assessed by a standardized questionnaire to predict posterior deep infiltrating endometriosis (DIE) among women with chronic pelvic pain symptoms. 134 women scheduled for laparoscopy for chronic pelvic pain symptoms completed a standardized self-administered questionnaire, specifically designed for the study. We compared the symptoms of the women with posterior DIE diagnosed at laparoscopy with those of the women with other disorders, and used multiple logistic regression analysis to select the best combination of symptoms for predicting posterior DIE. Cross-validation was performed with the jackknife method. 51 women (38.1%) were diagnosed with posterior DIE and 83 with other disorders (61.9%). The following variables were independent predictors for posterior DIE: painful defecation during menses, severe dyspareunia (visual analogic scale > or =8), pain other than noncyclic, and previous surgery for endometriosis. The cross-validation procedure leads to a simplified diagnostic model that uses two independent predictors: painful defecation during menses and severe dyspareunia. The sensitivity of this model for diagnosing posterior DIE was 74.5%, its specificity was 68.7%, its positive likelihood ratio was 2.4, and its negative likelihood ratio was 0.4. It correctly classified 70.9% of our sample into a high-risk (with either severe dyspareunia or painful defecation during menses) and a low-risk (neither symptom) group. Standardized evaluation of painful symptoms is useful for screening women so that they may have adequate exploration and counselling before laparoscopic surgery for pelvic pain symptoms.

Add-back therapy in the treatment of endometriosis-associated pain

To determine the efficacy of GnRH analogue plus add-back therapy compared with GnRH analogue alone and estroprogestin in patients with relapse of endometriosis-associated pain. Randomized, controlled study. University hospital. One hundred thirty-three women with relapse of endometriosis-related pain after previous endometriosis surgery. Forty-six women were treated with GnRH analogue plus add-back therapy, 44 women were given GnRH analogue alone, and 43 women received estroprogestin, for 12 months. Pain evaluation by a visual analogue scale, quality of life in treated patients according to the SF-36 questionnaire, and occurrence of adverse effects, including bone mass density loss, at pretreatment, after 6 months of treatment, at the end of treatment (12 months), and 6 months after discontinuation of treatment. Patients treated either with GnRH analogue alone or GnRH analogue plus add-back therapy showed a higher reduction of pelvic pain, dysmenorrhea, and dyspareunia than patients treated with oral contraceptive, whereas patients treated with add-back therapy showed a better quality of life, as assessed with the SF-36 questionnaire, and adverse effects rate than the other two groups. Add-back therapy allows the treatment of women with relapse of endometriosis-associated pain for a longer period, with reduced bone mineral density loss, good control of pain symptoms, and better patient quality of life compared with GnRH analogue alone or oral contraceptive.

Endometrial release of soluble intercellular adhesion molecule 1 and endometriosis: relationship to the extent of the disease

Objective: To relate endometrial release of the soluble form of intercellular adhesion molecule 1 with extent of endometriosis. Methods: Samples of endometrium were collected from 23 women with endometriosis. Soluble intercellular adhesion molecule 1 was quantified in conditioned medium from 48-hour endometrial stromal cell cultures with use of a specific enzyme-linked immunosorbent assay. Levels were correlated with revised American Society for Reproductive Medicine classification score for adhesions, implants, and cysts and total score; number of endometriotic implants; cyst diameter; and presence or absence of pelvic pain symptoms and previous surgical procedures for endometriosis. Results: Endometrial release of soluble intercellular adhesion molecule 1 directly correlated with number of implants ( r = .64, P < .005) and score for implants ( r = .61, P < .005). There was no significant correlation between levels of the soluble molecule and score for adhesions or total score. Soluble intercellular adhesion molecule 1 shed by endometrium did not correlate with the score for ovarian cysts, although an inverse relationship was found with ovarian cyst diameter ( r = –0.52, P < .05). No differences were detected between women who had pelvic pain and those who did not and between those who had previous surgery for endometriosis and those who had not. Conclusion: The association between endometrial release of soluble intercellular adhesion molecule 1 and the number and score of endometriotic implants suggests that the molecule might be of value in evaluating spread potential of refluxed endometrium.

Recurrence of ovarian endometrioma after laparoscopic excision

Objective: Our purpose was to evaluate the recurrence rate after laparoscopic excision of ovarian endometrioma. Study Design: An unrandomized prospective clinical study was performed at 2 tertiary-care centers of 366 patients who had a minimum of 6 months of postoperative follow-up or 6 months after the suspension of medical therapy after laparoscopic ovarian endometrioma excision. Patients underwent clinical examination and vaginal ultrasonography 3, 6, and 12 months after surgery and subsequently at least once a year. We evaluated the cumulative recurrence rate of pain and clinical findings of ovarian endometrioma, the rate of repeated surgery, and the recovery of fertility. Results: During follow-up we observed ultrasonographic recurrence in 26 (7.1%) cases; surgery was repeated in 12 (3.3%) cases. The cumulative rate of ultrasonographic recurrence over 48 months was 11.7%, whereas the cumulative rate of a second surgery was 8.2%. Ultrasonographic cyst recurrence was associated with pain recurrence in 73% of cases, whereas in the remaining 27% the recurrence was asymptomatic. Significant factors related to recurrence of endometriomas would appear to be the stage of disease (P = .03) and previous surgery for endometriosis (P = .003). Eighty-five (23.2%) women conceived during follow-up. Conclusions: Laparoscopic treatment of endometriomas seems to be both effective and reliable. The rate of recurrence appears to be correlated to the duration of follow-up. Stage IV disease and previous surgery for endometriosis are unfavorable prognostic factors. (Am J Obstet Gynecol 1999;180:519-23.)

Laparoscopic Hysterectomy

The first laparoscopic hysterectomy is described. Surgical techniques included aquadissection to develop appropriate tissue planes and bipolar electrosurgery to achieve hemostasis. The 38-year-old woman who elected to undergo this procedure had persistent pelvic pain secondary to pelvic adhesions from previous endometriosis surgery and hypermenorrhea due to uterine myomas. She was discharged on the fourth postoperative day and returned to full activity within 3 weeks. This case illustrates that hysterectomy can be accomplished using laparoscopy as the mode of access. In the future, titanium laparoscopic staples may replace bipolar electrosurgery for hemostasis. In selected patients, the laparoscopic approach to hysterectomy may avoid the increased morbidity associated with abdominal surgery while retaining the surgical advantages of the abdominal approach, i.e., thorough visualization and easy access to the vascular pedicles. (J GYNECOL SURG 5:213, 1989)

Operative treatment of rectal endometriosis.

27 patients with rectal endometriosis were operated upon in Turku University Central Hospital in 1967-1976. The main symptom was defecation pain especially during menstruation. Eighteen patients had had previous surgery for endometriosis of the pelvic area. A palpable tumor was found on gynaecological examination in every patient. The tumors did not grow through the rectal wall. Three kinds of operative procedures were applied (a simple excision method, a so called "window" operation, and resection of rectum) and the results were good.

Management of Endometriosis in the Infertile Patient

Infertility has a 30-40% incidence in women with endometriosis. However, conservative surgical procedures can result in pregnancy for 40-90% of these patients. The pregnancy rate is influenced by 5 factors: 1) extent of the disease, 2) age, 3) history of previous surgery for endometriosis, 4) duration of infertility before surgery, and 5) length of postsurgical follow-up. The factor responsible for infertility among women with endometriosis is believed to be an inadequacy of the tubo-ovarian motility secondary to fibrosis and scarring, which results in imperfect ovum acceptance by the fimbriae. Therapy encompasses 4 approaches: 1) prophylaxis, 2) observation and analgesia, 3) suppression of ovulation, and 4) surgical treatment. Pregnancy is suggested as the optimal prophylactic treatment for endometriosis since the symptoms and signs regress during gestation and for varying periods thereafter. This regression is probably due to a combination of anovulation and amenorrhea caused by adenohypophyseal suppression. It may also be due to a transformation of functioning endometriotic tissue into decidua by increasing levels of chorionic estrogen and progesterone. If pregnancy is not desired, anovulation can be secured by the administration of sex hormones. Pseudopregnancy for 6 months, induced by norgestrel plus ethinyl estradiol or norethynodrel plus mestranol, can lead to pregnancy in 50% of patients whose only abnormality is surface ovarian endometriosis within 1 year of cessation of therapy. Short periods of pseudopregnancy are also advocated after conservative surgery if all areas of endometriosis cannot be excised. 40-50% of these patients can expect to become pregnant within 24 months. The incidence of postoperative tubo-ovarian adhesions may be diminished by use of dexamethasone and promethazine.

Conservative treatment of endometriosis with progestin therapy

22 cases of endometriosis were treated with norethynodrel and conservative surgical therapy. Ovarian preservation was maintained. 20 mg a day of norethynodrel was given continuously for 60 to 120 days a smaller dose than previously reported by others. When breakthrough bleeding occurred dosage was increased to 30 or 40 mg daily. Only mild nausea or breast engorgement were frequent complaints. Patients ranged from 22 to 40 years of age; pelvic pain had been the most common symptom dysmenorrhea had been present in 7 and infertility was associated in 13. Palpable ovarian tumors or cysts or nodularity and fixation of ovaries were present in 16; uterosacral and cul-de-sac nodules were in 11. Associated myoma uteri were felt in 3. Hysterectomy was performed for abnormal bleeding in 1 and for myomata in 2. 4 had had previous surgery for endometriosis. 2 patients are still under therapy. Of the remaining 20 all have had complete relief of symptoms and have negative findings on pelvic examination. 2 have become pregnant following norethynodrel therapy.