Surgical Treatment Of Ovarian Endometriomas Research Articles

Experience of using transvaginal sclerotherapy in the treatment of ovarian endometriomas.

Abstract Ethanol sclerotherapy is effective and safe method of surgical treatment for ovarian endometrioma. Destruction with 95% ethanol solution of the capsule allows minimal impact on the ovarian reserve. However, this method should be thoroughly evaluated for the possibility to be used more frequently in practice. Aim - determination of indications for the use of the technique of transvaginal sclerotherapy in surgical treatment of ovarian endometriomas. Materials and methods From the October 2021 to October 2023 17 patients with ovarian endometrioma (OMA) were operated in the Moscow Regional Research Institute of Obstetrics and Gynecology with sclerotherapy perfomed by transvaginal access. Clinical manifestations included pelvic pain (76.4 %), dysmenorrhea (82.3 %), dyspareunia (47.0 %), bowel symptoms (35.3 %), polymenorrhea (47.0 %) and infertility (64.7 %). 11 (64.7%) of patients had been previously operated because of ОМА. Results Postoperative level of antimullerian hormone (AMH) were slightly reduced (mean difference before and after the surgery was -0.47 ng/ml). Mean antral follicle count (AFC) in the both ovaries were 10.8 before surgery and 8.6 after surgery. The volume of the ovary decreased from 2 to 6 times after sclerotherapy of the endometrioma. Symptoms returned in 4 women. There were 6 recurrences of endometrioma (35.2%) noted with ultrasound control after 3, 6 and 12 months after operation. The absence of endometrioid detritus in the cyst capsule was detected in 64.8% cases. Conclusion Preliminary results allow us to recommend the following options for the use of sclerotherapy by transvaginal access with ultrasound control: For the endometriomas in women of reproductive age and patients planning pregnancy by ART with any level of ovarian reserve. For the recurrent, previously histologically confirmed, symptomatic endometriomas in women of reproductive age with no plans for pregnancy presently with a reduced ovarian reserve (AMH1.2 ng/ml) and with any level of ovarian reserve but with symptomatic endometrioma in only preserved ovary. Transvaginal access is applicable for symptomatic endometriomas in the women with a big number of operations in the past.

Perioperative outcomes in a nationwide sample of patients undergoing surgical treatment of ovarian endometriomas

To evaluate the perioperative outcomes of premenopausal women undergoing cystectomy or oophorectomy for ovarian endometriomas (OMAs) and other benign neoplasms. Retrospective cohort study. Clinical database containing information from 580 US hospitals. Women 18 to 50 years old who underwent ovarian cystectomy or oophorectomy for benign indications between 2010 and2020. We compared procedure route, length of hospital stay, and complication rates by surgical indication (OMA vs. other benign neoplasms) and surgical procedure (cystectomy vs. oophorectomy). Thirty-day perioperative adverse events following adnexal surgery, including conversion to laparotomy, blood transfusion, ileus, urinary tract injury, bowel injury, readmission, and death. We identified 120,208 ovarian cystectomies (28,182 OMAs and 92,026 other indications) and 53,476 oophorectomies (8,622 OMAs and 44,854 other indications). During cystectomy, patients with OMAs more commonly experienced conversion to laparotomy (5.1% vs. 3.1%) and readmission (8.5% vs. 7.1%). For oophorectomies, patients with OMAs less frequently had minimally invasive surgery (55.8% vs. 64.8%) or outpatient procedures (33.8% vs. 41.8%). Urinary tract and bowel injuries were rare. Multivariable logistic regression demonstrated that the presence of OMA predicted composite complications during cystectomy (adjusted odds ratio [aOR] 1.23, 95% confidence interval [CI] 1.18-1.28) but not during oophorectomy (aOR 1.05, 95% CI 0.99-1.12). Patients with OMAs had 1.37 times the odds of a composite complication during oophorectomy than during cystectomy (95% CI 1.28-1.47). Patients undergoing ovarian cystectomy for OMAs had higher rates of perioperative adverse events than patients undergoing ovarian cystectomy for other benign neoplasms. Laparotomies were performed more often during oophorectomies for OMAs than for other benign indications.

Perioperative Outcomes in a Nationwide Sample of Patients Undergoing Surgical Treatment of Ovarian Endometriomas

Study Objective Surgery for deep infiltrating and bowel endometriosis involves risks of organ injury, reoperation, and prolonged hospital stay. Surgical outcomes following surgery for ovarian endometriosis (endometrioma, OMA) are currently unknown. The objective of this study was to evaluate perioperative outcomes of premenopausal women undergoing cystectomy or oophorectomy for OMAs compared to other benign ovarian neoplasms. Design Retrospective cohort study. Setting Vizient Clinical Database, which contains information from 580 participating hospitals across the United States. Patients or Participants Patients ages 18-50 who underwent ovarian cystectomy or oophorectomy for benign indications 2010-2020 were identified. OMAs included ICD-9/10 codes for ovarian endometriosis. We excluded patients who received concomitant hysterectomy or obstetric or oncologic care. Interventions We abstracted clinical data, including surgical route, length of stay, and 30-day postoperative complication rates. Procedures performed for OMA were compared to other surgical indications. Measurements and Main Results We identified 58,874 patients who underwent oophorectomies (10,464 OMAs vs. 48,410 for other indications) and 125,911 ovarian cystectomies (30,058 OMAs vs. 95,853 other). During oophorectomy, patients with OMAs were less likely to undergo minimally invasive surgery (63% vs. 67%, p<0.001) and more likely to require conversion to laparotomy (4.3% vs. 3.4%, p<0.001) and extended hospitalization 2+ days (40% vs. 37%, p<0.001). Among women undergoing cystectomy, conversion to laparotomy (5.3% vs. 3.3%, p<0.001) and readmission (8.5% vs. 7.2%, p<0.001) were more common with OMAs. In multivariable logistic regression, OMA predicted conversion to laparotomy during oophorectomy (aOR 1.3, 95% CI=1.1-1.4) and cystectomy (aOR 1.6, 95% CI=1.5-1.7). Urinary tract injury was infrequent and occurred more often during surgery for indications other than endometriosis (oophorectomy 1.7% vs. 0.95%, cystectomy 0.74% vs. 1.3%, all p<0.001). Bowel injury was exceedingly rare (0.01% of all procedures). Conclusion We present population-level data demonstrating that patients undergoing ovarian cystectomy or oophorectomy for endometriomas had higher rates of perioperative adverse events, including conversion to laparotomy, extended hospital stay, and readmission. Surgery for deep infiltrating and bowel endometriosis involves risks of organ injury, reoperation, and prolonged hospital stay. Surgical outcomes following surgery for ovarian endometriosis (endometrioma, OMA) are currently unknown. The objective of this study was to evaluate perioperative outcomes of premenopausal women undergoing cystectomy or oophorectomy for OMAs compared to other benign ovarian neoplasms. Retrospective cohort study. Vizient Clinical Database, which contains information from 580 participating hospitals across the United States. Patients ages 18-50 who underwent ovarian cystectomy or oophorectomy for benign indications 2010-2020 were identified. OMAs included ICD-9/10 codes for ovarian endometriosis. We excluded patients who received concomitant hysterectomy or obstetric or oncologic care. We abstracted clinical data, including surgical route, length of stay, and 30-day postoperative complication rates. Procedures performed for OMA were compared to other surgical indications. We identified 58,874 patients who underwent oophorectomies (10,464 OMAs vs. 48,410 for other indications) and 125,911 ovarian cystectomies (30,058 OMAs vs. 95,853 other). During oophorectomy, patients with OMAs were less likely to undergo minimally invasive surgery (63% vs. 67%, p<0.001) and more likely to require conversion to laparotomy (4.3% vs. 3.4%, p<0.001) and extended hospitalization 2+ days (40% vs. 37%, p<0.001). Among women undergoing cystectomy, conversion to laparotomy (5.3% vs. 3.3%, p<0.001) and readmission (8.5% vs. 7.2%, p<0.001) were more common with OMAs. In multivariable logistic regression, OMA predicted conversion to laparotomy during oophorectomy (aOR 1.3, 95% CI=1.1-1.4) and cystectomy (aOR 1.6, 95% CI=1.5-1.7). Urinary tract injury was infrequent and occurred more often during surgery for indications other than endometriosis (oophorectomy 1.7% vs. 0.95%, cystectomy 0.74% vs. 1.3%, all p<0.001). Bowel injury was exceedingly rare (0.01% of all procedures). We present population-level data demonstrating that patients undergoing ovarian cystectomy or oophorectomy for endometriomas had higher rates of perioperative adverse events, including conversion to laparotomy, extended hospital stay, and readmission.

Results of Surgical Treatment of Ovarian Endometrioma

Objective: Diagnosing and treating ovarian endometrioma at the clinical stage and making a comparative study of the treatment results. Methods: In 2018-2019, 63 women aged 20-45 years diagnosed with ovarian endometriosis in the gynecology department of the Obstetrics and Gynecology Hospital of the National Center for Maternal and Child Health were included in the study. A hospital-based clinical prospective case-control study was used. Results: The first group of women received dienogest after surgery for 3 months during which pain during menstruation (p &lt; 0.001), pain during intercourse (p &lt; 0.001), and chronic pelvic pain (p &lt; 0.016) was assessed. The second group of women received dienogest before surgery for 3 months during which pain during menstruation (p &lt; 0.001), pain during intercourse (p &lt; 0.001), and chronic pelvic pain (p &lt; 0.001) was assessed. In this comparative surgical study, in the first group 14 (43.8) had trouble having the endometrioma removed, and in the second group, 23 (74.2%) had no trouble having the endometrioma removed. Conclusion: The use of synthetic progestin before surgical removal of moderate to severe endometriosis with laparoscopy decreases the blood loss during surgery (p &lt; 0.021) and facilitate the removal of the endometrium from the ovary

RECURRENCE, RE-OPERATION, AND PREGNANCY RATES AFTER SURGICALLY TREATED OVARIAN ENDOMETRIOMA IN A SINGLE INSTITUTION: LONG-TERM FOLLOW UP OF 756 WOMEN

The aims of this study were to evaluate the cumulative recurrence, re-operation, and pregnancy rates after surgically treated ovarian endometrioma in a single institution for more than a 5-year follow up period. This was a retrospective chart review of the patients with ovarian endometrioma who underwent surgery between January 2008 and March 2016. Study subjects included premenopausal women with at least 5-years of follow-up. Exclusion criteria were patients with stage I or II ovarian endometrioma by revised American Society for Reproductive Medicine (rASRM) classification, those who underwent hysterectomy or bilateral oophorectomy, and presence of residual ovarian lesions on the first postoperative ultrasonography at 3-6 months. Recurrent ovarian endometrioma was defined as a new cystic mass measuring 20 mm or more on the ultrasonography. A total of 756 patients were recruited. The mean age was 31.8±6.3 years (median 31 years, range, 16-54 years) and the mean follow-up duration was 90.4±23.3 months (median 85.5 months, range, 60-155 months). Recurrent ovarian endometrioma was detected in 27.9% (211 of 756 patients), and re-operation was performed in 8.3% (63 of 756 patients). Total 29.9% (63 of 211 patients) with recurrent endometrioma was treated with repeated surgery. Using the Kaplan-Meier method, the cumulative recurrence rate at 24, 36, 60, and 120 months after surgical treatment of ovarian endometrioma was calculated as 5.9%, 8.7%, 15.5% and 37.8%, respectively. The cumulative re-operation rate at 24, 36, 60, and 120 months was 0.3%, 1.1%, 3.1% and 15.6%, respectively. After multivariate analyses, age ≤ 31 years (hazard ratio [HR]=2.108; 95% confidence interval [CI]=1.522-2.921; p<0.001), no subsequent pregnancy (HR=1.851; 95% CI=1.309-2.617, p<0.001), postoperative hormonal treatment ≤15 months (HR=2.869; 95% CI=2.088-3.941); p<0.001) were significant risk factors for recurrent ovarian endometrioma. Among the study patients, 316 (41.7%) women desired future pregnancy, and 171 of 316 (54.1%) were able to conceive and had uncomplicated delivery. Eighteen (5.7%) women experienced spontaneous abortion or ectopic pregnancy, and 36 (11.4%) women were either pregnant at the time of data collection or lost to follow up after confirming intrauterine pregnancy. Among the 316 patients who desired pregnancy, 91 (28.8%) failed to conceive. Considering the fact that longer postoperative hormonal treatment is the sole modifiable factor for recurrent ovarian endometrioma, we recommend long-term hormonal treatment until subsequent pregnancy, especially in younger age group.

Hyperactivation of dormant primordial follicles in ovarian endometrioma patients.

Serum anti-Müllerian hormone (AMH) levels decrease after surgical treatment of ovarian endometrioma. This is the main reason that surgery for ovarian endometrioma endometriosis is not recommended before in vitro fertilization, unless the patient has severe pain or suspected malignant cysts. Furthermore, it has been suggested that ovarian endometrioma itself damages ovarian reserve. This raises two important challenges: (1) determining how to prevent surgical damage to the ovarian reserve in women with ovarian endometrioma and severe pain requiring surgical treatment and (2) deciding the best treatment for women with ovarian endometrioma without pain, who do not wish to conceive immediately. The mechanisms underlying the decline in ovarian reserve are potentially induced by both ovarian endometrioma and surgical injury but the relative contribution of each process has not been determined. Data obtained from various animal models and human studies suggest that hyperactivation of dormant primordial follicles caused by the local microenvironment of ovarian endometrioma (mechanical and/or chemical cues) is the main factor responsible for the decreased primordial follicle numbers in women with ovarian endometrioma. However, surgical injury also induces hyperactivation of dormant primordial follicles, which may further reduce ovarian reserve after removal of the endometriosis. Although further studies are required to elucidate the mechanisms underlying diminished ovarian reserve in women with ovarian endometrioma, the available data strongly suggests the need to prevent/minimize hyperactivation of dormant primordial follicles, regardless of whether surgery is performed, for better clinical management of ovarian endometrioma.

Atypical endometriosis is related to a higher recurrence rate

ObjectivesThe aims of this study were to evaluate the clinical characteristics and recurrence rate of atypical endometriosis (AE)11AE: Atypical endometriosis, ASRM: American Society of Reproductive Medicine, EAOC: Endometriosis-associated ovarian cancer, RR: Relative risk, TE: Typical endometriosis. compared to typical endometriosis (TE) in addition to the malignant transformation rate among a large cohort. Study designThe medical records of 2681 patients who had undergone surgical treatment of ovarian endometrioma between January 2008 and September 2019 were retrospectively reviewed. The patients were divided into AE (n = 86) and TE (n = 2595) groups. Patients’ characteristics and recurrence rates were evaluated and compared between the two groups. ResultsThe mean size of ovarian cysts was significantly larger in the AE group (7.6 ± 3.5 cm vs 6.7 ± 3.3 cm, p = 0.01) and the proportion of nulliparous women was significantly lower in AE group (65.1 % vs 77.8 %, p = 0.008). Otherwise, there were no statistically significant differences in patient characteristics between the two groups. After Cox regression analyses with IPTW was adjusted, the risk factors for recurrent endometrioma were higher preoperative CA125 level >48 U/mL (hazard ratio [HR] = 2.741; 95 % confidence interval [CI] = 1.517−4.952; p < 0.001), multilocular cyst (HR = 1.909; 95 % CI = 1.128−3.230; p = 0.016), and atypical endometriosis (HR = 2.666; 95 % CI = 1.659−4.284; p < 0.001). The AE group displayed a significantly higher cumulative recurrence rate than the TE group (p = 0.0057, log-rank test). No patients were diagnosed with atypical endometriosis to malignant transformation during the follow-up periods. However, two typical endometriosis patients experienced borderline malignancy and serous carcinoma, respectively. ConclusionRecurrence rates for AE were higher than for TE. Although the AE group included no patient with malignant transformation in this study, considering the higher recurrence as well as the possibility of malignant transformation, long-term close surveillance is warranted.

Surgical treatment of ovarian endometriomas using intraoperative ultrasound

Aim. To improve the results of the surgical treatment of patients with ovarian endometriomas using intraoperative echography.Materials and methods. The results of the surgical treatment of 138 patients with endometrioid ovarian cysts were prospectively and retrospectively analyzed. The main group consisted of 69 patients, who underwent standard ultrasound examination before and after surgery, as well as intraoperative laparoscopic ultrasound imaging. The control group (retrospectively) consisted of 69 patients with endometrioid ovarian cysts, who were not subject to laparoscopic ultrasound examination.Results. The use of intraoperative transvaginal and laparoscopic echography can reduce the time of surgical revision, reduce the number of intra- and postoperative complications, as well as the frequency of relapses in the postoperative period.Conclusion. According to the obtained results, intraoperative ultrasound echography has a high diagnostic accuracy of up to 99.2%. This method of intraoperative diagnosis allows the optimal volume and method of surgical intervention to be determined, and the safety and adequacy of surgical treatment to be ensured, thus maximizing the reproductive function.

An alternative method of surgical treatment of ovarian endometriomas from the standpoint of preservation of the ovarian reserve

Hypothesis/aims of study. Ovarian endometriomas are a great danger to the female reproductive function. In addition to the negative impact of the disease itself on ovarian reserve, the reproductive capabilities of women are influenced by surgery on the ovaries and subsequent hormonal therapy. Ovarian reserve after cystectomy of the endometriomas suffers more than after removal of other benign ovarian tumors. The solution of the problem can be obtained using sclerotherapy during laparoscopy. The aim of this study was to assess the impact of sclerosing endometriomas during laparoscopy on the ovarian reserve.&#x0D; Study design, materials and methods. The study involved 36 patients aged 2535 years. Inclusion criteria were genital endometriosis, endometrioma of one of the ovaries with a volume of 15100 cm3, and pregnancy planning. Exclusion criteria were uterine fibroids, endometrial hyperplasia, polycystic ovary syndrome, and the previous operations on the ovaries and uterine tubes. The main group consisted of 18 patients who underwent sclerotherapy of an endometrioma during laparoscopy with a 70% ethanol solution. The comparison group comprised 18 patients who underwent cystovariectomy with bipolar coagulation of the tumor lining. Within 4 months after surgery, gonadotropin-releasing hormone agonists were administered. An ultrasound examination of the pelvic organs and determination of anti-Mllerian hormone (AMH) level were performed before surgery, after surgery, and after hormonal treatment.&#x0D; Results. In both study groups, AMH level decreased immediately after surgery: in the main group, it reduced by 1.4 times, in the comparison group by 2.4 times. After termination of therapy with gonadotropin-releasing hormone agonists and recovery of the menstrual cycle, AMH level increased slightly (it was 2.9 0.40 ng/ml in the main group, and 1.8 0.24 ng/ml in the comparison group). Within 12 months after surgery, pregnancy occurred in 44.4% of patients in the main group and in 33.3% of patients in the comparison group. Over 16 months of follow-up, not a single case of recurrence of the disease was subsequently detected.&#x0D; Conclusion. Sclerotherapy of endometriomas during laparoscopy is supposed to be an effective and promising technique aimed at preserving the ovarian reserve in this category of patients.

Optimization of surgical treatment of ovarian endometriomas in reproductive age

Optimization of surgical treatment of ovarian endometriomas in reproductive age

Endometrioma: por qué y cuándo debe ser operado antes de los trata mientos de infertilidad

La endometriosis es una de las enfermedades más enigmáticas de la ginecología y en general de la profesión médica. Su patogénesis sigue siendo desconocida. La forma de presentación es bizarra, ya que hay mujeres que tienen endometriosis y presentan dolor y/o infertilidad y hay mujeres que teniendo endometriosis no presentan ni dolor ni infertilidad. Asimismo, muchos aspectos de su manejo continúan siendo controversiales, y el tratamiento del endometrioma no escapa a esta situación. Diversos tratamientos tanto médicos como quirúrgicos han sido propuestos con resultados variados, pero quizás el aspecto más controversial es el relacionado con el tratamiento quirúrgico del endometrioma ovárico. Siempre ha sido manifiesta la relación entre el endometrioma y la infertilidad, y el tratamiento de elección siempre ha sido el quirúrgico, más aún con la evidencia de un incremento de la fertilidad después de la cirugía. Pero, con el advenimiento de la fertilización in vitro (FIV) aparecieron dudas con respecto al real beneficio de la cirugía para mejorar la fertilidad en mujeres con endometrioma, ya que fueron apareciendo algunos estudios que refirieron el impacto negativo de la cirugía en la reserva ovárica al remover tejido ovárico sano junto con la cápsula del endometrioma, en el momento de la cirugía. Pero, es importante resaltar que el endometrioma no solamente genera infertilidad sino que muchas veces la molestia más prevalente es el dolor, y que muchas de estas pacientes no son infértiles. Por esto, el objetivo de esta revisión de las controversias es tratar de establecer a la luz de las evidencias el estado actual del manejo del endometrioma en general y el impacto del tratamiento quirúrgico en la fertilidad en lo particular.

Use of depot GNRH antagonist (Degarelix) in the treatment of endometriomas (ovarian endometriosis) before IVF: a controlled trial

Use of depot GNRH antagonist (Degarelix) in the treatment of endometriomas (ovarian endometriosis) before IVF: a controlled trial

Ovarian stripping versus cystectomy: recurrence of endometriosis and pregnancy rate

To compare two different surgical techniques, stripping or cystectomy, in patients treated with the same post-operative medical therapy in terms of recurrence of endometrioma, recurrence of pain and spontaneous pregnancy rate within 2 years from surgery. The inclusion criteria of this study were: (1) 25-40 years old; (2) ovarian endometrioma more than 3 cm of diameter detected by transvaginal ultrasonography (3) regular menstrual cycle (4) post-operative treatment with GnRH analogs, (5) tubal patency assessed by laparoscopic chromopertubation (6) normal human semen characteristics. Exclusion criteria were uterine myoma, previous medical treatment for endometriosis, presence of adenomyosis, previous surgery of ovarian endometrioma, multiple cysts, bilateral involvement, co-existence of deep endometriosis. Patients were assigned to two study groups: group A (N = 45) patients undergoing stripping technique and group B (N = 64) patients undergoing cystectomy technique for ovarian endometrioma. In group B the percentage of ultrasonographic recurrence (15.4 %, N = 15) is much lower than in group A (55.6 %, N = 25). (p value 0.001). In group B the percentage of symptomatic recurrence (21.8 %, N = 14) is much lower than in group A (53.3 %, N = 24) (p value 0.001). Spontaneous pregnancy rate in group A patients was of 4.4 % (N = 2) and in group B 22.3 % (N = 21), (p value 0.0072). However, the percentage of specimen with adjacent healthy ovarian tissue was lower in group A (26.6 %) than in group B (50 %) (p value 0.01). Among the different treatment options for surgical treatment of ovarian endometrioma, in our experience cystectomy appears to be the most appropriate treatment, both in terms of recurrence and pregnancy rate.

Management of Infertile Women with Endometriosis. What's the Result of Leaving Ovarian Endometrioma during IVF-ET Cycles?

Purpose The awareness of possible risk of damage to ovarian reserves after surgical treatment of ovarian endometriomas supports a more conservative approach in infertile women with ovarian endometrioma. A growing number of patients with ovarian endometrioma undergo In Vitro Fertilization and Embryo Transfer (IVF-ET) prior to surgery. The aim of this study was to assess the effect of ovarian endometrioma on IVF-ET cycles. Methods In a retrospective cohort pilot study, IVF-ET cycles performed by our group during the period 2000–2004 were assessed. One hundred and forty-four women with a history of surgery for endometriosis or endometriosis at the time of the cycle were included in the ‘study group'. Seventy infertile patients because of tubal factor constituted the ‘control group'. IVF-ET outcome was assessed. Results Patients with endometriosis required a higher total dosage of FSH/hMG and attained lower peak E2 levels, and fewer follicles and oocytes were obtained. Clinical pregnancy rate per patient was lower in the endometriosis group (24/144, 16.7%) when compared with tubal factor (20/70, 28.6%), clinical pregnancy rate per embryo transfer was similar (24/117, 20.5% and 20/61, 32.8% respectively). When stratifying results in the endometriosis group, patients with a history of prior surgery for ovarian endometrioma required a higher dosage of FSH/ hMG and attained a lower peak of estradiol. A trend with a consistent reduction in pregnancy rate in women with a history of prior surgery for ovarian endometrioma (5/37, 13% in patients with previous cystectomy and no recurrence; 2/17, 11.8% in patients with prior surgery and recurrence of endometrioma at pick-up; 2/10, 20% in women never operated with endometrioma at pick-up; 15/53, 28.3% in the minimal-mild endometriosis group; 20/61, 32.8% for tubal factor) was observed. Conclusions Both surgery for ovarian endometrioma and the existence of endometrioma during pickup appear to affect IVF-ET outcome. Patients with prior surgery and endometrioma recurrence at the time of pick-up revealed a further decrease in pregnancy rate.

Combined technique of excision and ablation for the surgical treatment of ovarian endometriomas: the way forward?

Surgical treatment of ovarian endometriosis has been associated with damage to the ovarian tissue and premature ovarian failure in young patients. A modified surgical technique that combines cyst excision with ablation for the surgical treatment of ovarian endometriomas is presented, with the aim of reducing possible damage to the ovarian tissue without jeopardizing the results of surgery in terms of subsequent pregnancies and symptom relief. The modified technique is a combination of the excision technique, adopted for most of the procedure, with the coagulation technique, adopted at the ovarian hilus to better preserve normal ovarian tissue and vascularization of the ovary. Postoperative follow-up of patients operated on with this modified technique indicates that the technique is feasible and safe, with no apparent damage to the ovary.

Sclerotherapy with 5% tetracycline is a simple alternative to potentially complex surgical treatment of ovarian endometriomas before in vitro fertilization

Objective Conventional treatment of endometriosis involves drainage and removal of the cyst wall, which often results in inadvertent resection of normal ovarian tissue. We previously reported that 12 patients were successfully treated with sclerotherapy using 5% tetracycline. We now report our experience with sclerotherapy before in vitro fertilization (IVF) in an additional 20 patients with ovarian endometriomas. Design Prospective, cohort. Setting Private practice. Patient(s) Women (n = 32) with sonographic evidence of an ovarian endometrioma were offered sclerotherapy in lieu of laparoscopy. Intervention(s) Sclerotherapy was performed under conscious sedation and transvaginal ultrasound guidance. An 18-guage, single-lumen needle was inserted into the endometrioma, and the cyst contents were sequentially aspirated and flushed with sterile saline until the aspirated fluid was clear. Tetracycline (5%) (5–10 mL) was then instilled into the cyst. Saline was injected into the cul-de-sac to dilute any tetracycline that may have leaked. The fluid was then removed. Ultrasound was performed 6 weeks later to assess the efficacy of treatment. Main outcome measure(s) Resolution of endometrioma and subsequent IVF pregnancy rate. Result(s) Complete resolution was observed in 24 (75%) of 32 patients, at follow-up exam. Repeat aspiration of watery fluid was required in eight patients before resolution. Repeat treatment with tetracycline was needed in two patients. Only one patient did not ultimately respond. In vitro fertilization was performed in 28 patients; an ongoing gestation resulted in 16 (57%) from the next cycle. Conclusion(s) Sclerotherapy with 5% tetracycline is a simple, effective (and, in our limited series, safe) alternative to surgical intervention for treatment of endometriomas before IVF.

Removal of endometriomas before in vitro fertilization does not improve fertility outcomes: a matched, case–control study

Objective To investigate whether conservative surgery on ovarian endometriomas before an IVF cycle improves fertility outcomes. Design Retrospective, matched case–control study. Setting Two academic IVF programs. Patient(s) One hundred eighty-nine women with endometriomas who underwent IVF treatment: 56 women proceeded directly to IVF, and 133 first underwent conservative ovarian surgery. Intervention(s) Controlled ovarian hyperstimulation and IVF-ET. Main outcome measure(s) Response to gonadotropins, fertilization, implantation, and pregnancy rates. Result(s) Aside from lower peak E 2 levels on the day of hCG and a higher total FSH dose in women previously operated for an endometrioma, no significant differences were found between the two groups in the different IVF variables analyzed. Conclusion(s) Laparoscopic cystectomy for endometriomas before commencing an IVF cycle does not improve fertility outcomes. Proceeding directly to controlled ovarian hyperstimulation in women with asymptomatic ovarian endometriomas might reduce the time to pregnancy, the costs of treatment, and the hypothetical complications of laparoscopic surgery. Conversely, conservative surgical treatment of ovarian endometriomas in symptomatic women does not impair IVF or intracytoplasmic sperm injection success rates.