Supplement 12015, 4th ISAA [628599]

Supplement 1/2015, 4th ISAA

THE RATE OF SPONTANEOUS PREGNANCY AFTER LAPAROSCO PIC TREATMENT
FOR ENDOMETRIOSIS

Raluca Gabriela SUBA, Ion IONUT and Bogdan MARINESCU

“Profes sor D r Panait Sirbu “ Obstetrics and Gynecology Hospital , Bucharest, Romania
Corresponding Author: Raluca Gabriela SUBA , E-mail raluc [anonimizat]

Accepted November 16, 2015

No consensus exist on how to manage patients with ovarian endometriomas and deep endometriosis regarding the
impact on fertility preservation and recurrence rates. There is a retrospective study accomplish in “ Professor Dr.
Panait S irbu Hospital” among 3 years. The study included patients with ovarian endometriosis and deep endometriosis
who have also associated primary in fertility and secondary infertility . 112 women included in this study had
lapar oscopic cystectomy (unilateral/ bilateral) and excision of pelvic endometriosis implants. The patients complete a
questionnaire regarding a pain scale and quality of life. From the 112 women included in this study, only 79 wanted to
conceive and 51 get pregnant. Only 4 women said that they did not feel any improvement regarding the quality of life
and the rate of pain re currence was 2,6% (3 patients) at 6 month and 8 % (9 patients) at 12 month.

Key words: endometriosis, pregnancy, infertility, pain scale, quality of life.

INTRODUCTION

Endometriosis is a common gyn ecological disorder in
which endometrial tissue ( glandular ep ithelium and
stroma ) is found outside the uterine cavity.
Characteristic symptoms include dyspareunia, severe
dysmenorrhea and chronic pelvic pain1. Endometriosis
mostly presents as ovarian cysts and superficial and deep
pelvic peritoneal implants and adhesions. Endometriotic
ovarian cysts can be reliably identified by transvaginal
ultrasound. A trained sonographer can easily distinguish
endometriomas from other ovarian cysts for their
characteristic echogenic appearance. Instead, detection of
peritoneal implants and adhesions requires direct
visualization of the pelvis through a laparoscopic
examination. Classically it has been claimed that about
10% of women in the reprod uctive age have
endometriosis2, although such affirmation lacks of a solid
background. . Endometriosis is t he third leading cause of
gynecologic hospital ization in the United States3.
The prevalence in women undergoing laparoscopy
because of infertility was from 2.1% to 77.1% and in
women undergoing laparoscopy for pelvic pain was
2.15 to 83.6%. Many of these different access to
laparoscopy (indications, previous work -up, general
availabi lity of infertility treatments)4. It seems that there
is an increasing frequency of reporting endometriosis,
although it is not clear whether this corresponds to a
true increase in the occurrence of endometriosis or to
improved diagnosis.
There are still controversy regarding if endometri osis
cause infertility. What is easy to conclude is that
endometriosis can cause mechanical infertility because
of destruction of ovarian tissue, adhesions with
distortion of pelvic architecture interfering with the
release of the oocytes and the tubal pi ck-up of these oocytes, fimbrial distortion or occlusion, hydrosalpinx
or proximal tubal
obstruction . However, there is controversy about
whether minimal endometriosis causes infertility.
Surgical treatment of superficial endometriotic lesions
and ovarian endometriomas has been properly classified
now. Laparoscopic surgery has become the gold
standard for treatm ent of ovarian endometriosis5. A
Cochrane review concluded that excisional surgery of
ovarian endometriosis results in a more favorable
outcome than drainage and ablation with regard to
recurrence, pain symptoms and subsequent spontaneous
pregnancy in women who were previously subfertile6.
However, both excision and ablation may damage
normal ovarian cortex. The current technique of ovarian
endometrio ma capsule excision may lead to the removal
of normal ovarian tissue, causing loss of follicles7. On
the other hand, capsule ablation may lead to thermal
(heat) damage to the underlying ovarian cortex8.
It is well known that medical therapy alone has a lim ited
role in the treatment of endometriomas. Conservative
medical treatment, independently of the prescribed
product, may lead simply to a reduction in volume
rather than complete regression9.
A wide spectrum of non -medical options has been
proposed. The ultrasound -guided aspiration, although
feasible, is associated with a high rate of recurrences
even when combined with systemic or local medical
treatments. Regardless of the technique applied,
pregnancy rates after laparoscopic treatment of
endometriosis have been repor ted to vary between 23
and 67% 10-12. Several factors may explain the wide
variation in the success percentages. In particular,
pregnancy rate may be significantly influenced by the
number and characteristics of patients enrolled, length
of follow -up, selection criteria, adhesion score and
surgical technique.
Proc. Rom. Acad., Series B, 2015 , Supplement 1, p. 222 -224

MATERIAL AND METHODS

It is a retrospective study accomplish in “Prof. Dr
Panait Sirbu ” Hospital among 1st of January 2011 and
31 of December 2013 and included 112 patients . Age
range was 18 -40 years. The study included all of the
patients who have been diagnosed with endometriosis
(unilateral or bilateral ovarian cysts, d eep infiltrating
endometriosis), who have also primary and secondary
infertility.
The diagn ostic suspici on was made using a detailed
anamnesis, clinical examination and pelvic ultrasound
scans. The common symptoms associated with
endometriosis are dysmenorrhea , pelvic pain at other
times of the menstrual cycle and dyspareunia. The
presence of these symptom s was used as a screening test
to identify patients requiring the “gold standard”
diagnostic test of a laparoscopy.. Clinical examination
consisted in a r outine colposcopy and vaginal tact. The
symptoms described was pain at the level of the ovary ,
vaginal pain with rectal irradiation and rectovaginal
nodules.
The only widely accepted use of ultrasound in
diagnosing endometriosis is in the detection of ovarian
endometriomas. An endometrioma, or “ chocolate cyst”
may be unilateral or bilateral. The endometrio ma is
filled with old blood, gi ving a typical ground -glass
appearance with low -level echoes . Ultrasound has a
high sensitivity and specificity for diagnosing ovarian
endometriomas, but has been relatively poor at
diagnosing peritoneal endometriosis.
The di agnosis was made during laparoscopy. The
surgical procedure requires a general anesthetic for the
patient, and provides a panoramic view of the pelvis
from the ombilical port site after insu fflation of the
peritoneal cavity with CO2 gas.
The severity of the endometriosis was scored ac cording
to the revised American Society for Reproductive
Medicine Classification. A score is assigned to
endometriotic lesions on the peritoneum and ovaries
(based on size, location and depth), to posterior cul de
sac endomet riosis (partial and complete obliteration),
and to adhesions on the ovaries and tubes (based on
whether adhesions are filmy or dense, and the
proportion of the tube or ovary covered). Stage of
disease is divided into: Stage I (minimal) -score 1 -5;
Stage II (mild) -score 6 -15; Stage III (moderate) -score
16-40; Stage IV (severe) –score > 40.
The 112 women included in this study benefited by
laparoscopic cystectomy (unilateral/ bilateral) and
excision of pelvic endometriosis implants. To minimize
inter-operato r variability in surgical technique, we
included only laparoscopic treatment performed by the
same experimented surgery teem. (I.I, B.I, H.A, S.R)
The ESHRE, the American Society for Reproductive
Medicine and the Royal C ollege of Obstetricians and
Gynecolo gist, published guidelines and
recommendation for the management of women with
endometriosis. There is general agreement on most
issues regarding the suggested clinical conduct in the
case of endometriosis -associated infertility. The three
organizations re commend surgery for peritoneal
endometriosis (stage I -II disease), although ESHRE and ASRM acknowledge that the benefit is limited.
Consensus also exist on ovarian endometriomas (stage
III-IV disease), as the effect of surgery is always
defined “possible”. In spite of this consideration,
ESHRE and ASRM suggest surgical removal of
endometriotic cysts, whereas the RCOG does not give a
specific indication .
According to the protocols, all of the 112 patients
enrolled in the study followed laparoscopic surgery.
Brifly, the surgery procedures : introduce the trocars,
first (ombilical trocars), the second one a t the level of
left iliac fossa , third one above the pubic symphysis and
the forth one at the level of right iliac fossa. Inspection
of the abdominal and pelvic cavities, (Figure 1)
adesiolysis, remove the ovaries from the ovarian fossa,
if the ovaries are bulky , then it is useful to suspend them
at the abdominal wall. If the e ndometriomas are greater
then 4 mm it can be use ful to break the cyst and to aspire
the chocolate liquid in order to improve the view. View
with dissection both ureters, d eep infiltrating
endom etriosis was completely excised (Figure 3) using
mechanical instruments and electrosurgery (monopolar
and bi polar). Peritoneal superficial endome triotic
lesions were excised or coagulated with bipolar current.
Patients with colorectal endometriosis received excision
of nodules by shaving. (Figure 2) There was some
cases12 with deep infiltrating colorectal nodules which
requires disc excision or colorectal resection, but our
hospital does not benefit from a digestive surgeon.
There was no patients with large colorectal infiltration
responsible for advanced stenosis. Ovarian
endometriosis were excised by the stripping technique
at the end of the surgery .

Figure 1 Preoperative Evaluation
Figure 2 Shaving of colorectal n odules 223

Post-operatively, the su rgeon advised patients on their
capacity to conceive and recommended attempting
spontaneous conception. After histopathological tests
confirmed endometriosis, the patients were included in
the study. The patients signed the informe d consent
before inclusion in the study, and this study was
approved by Ethical Committee.

RESULTS AND DISCUSSIONS

From the 112 women who were treated for
endometriosis between 2011 and 2013, only 79 wanted
to conceive and 51 get pregnant (64,55%). 34 obtained
spontaneous pregnancy and 17 an IVF pregnancy. In
group of 79 patients who wanted to get pregnant 58 had
a personal history of infertility.
Regar ding the quality of life in the presen t, the patients
responded : very much (63) (56,25%), a lot (36)
(32,14%), a little (9) (8,03%), at all (4) (3,57%).
The pain re currence was 2,6% (3 patients) at 6 month
and 8% (9 patients) at 12 month. The most commonly
and upsetting symptom was dysmenorrhea (Figure 4 )
described by 76 patients ( 67,85 %),followed by
dyspareunia 21 patients ( 23,52 %) and rectal pain 15
patients ( 16,8%).

Postoperative medical treatment (GnRH agonist, oral
contraceptive, oral progesterone) was not given to the
patients, because that could have hidden the recurrence
of the disease and could have made the pregnancy
impossible

CONCLUSIONS

Surgical procedures used (cystectomy, excision of
peritoneal endometrial implants, rectovaginal shaving) allows a high rate of postoperative spontaneous
pregnancy and a low rate of pain recurrence. The rate of
pregnancy after laparoscopic trea tment for
endometriosis ( 64,55%) was similar with other studies
(66,9%)13. Endometriosis is a complex disease that can
involve the urinary bladder, the ureter, colon and the
rectum. W e suggest an operating team composed of a
gynecologist, a general surgeon and an urologist . The
technical skill, operative experience and techniques
used by the surgeon are the most important factors
which determine the outcome of endometriosis surg ical
treatment.

Acknowledgment This work was co -financed from the European
Social Fund through Sectoral Operational Programme – Human
Resources Development 2007 -2013”, project number POSDRU 187
/1.5/S/1556 31, entitled “Scientific excellence, knowledge and
innovation through doctoral programs in priority areas”, Beneficiary
– Medicine and Farmacy University ”Carol Davila” Bucharest .

REFERENCES

1.Hart R. Unexplained infertility , endometriosis and fibroids
BMJ , 2003, 327, 721-724
2.Eskenazi B, Warner ML Epidemiology of endometriosis.
ObstetGynecol Clin North Am 1997;24 -235-58
3. Velebil P Wingo PA Xia Z . Wilcox LS, Peterson HB. Rate
of hospitalization for gynecologic disorders among
reproductive -age women in the United States. Obstet Gynecol
1995;86:195 -99
4. GuoSW, Wang Y. Sources in heterogeneities in estimating
the prevalence of endometriosis in infertile and previously
fertile women Fertil Steril 2006; 85:1584 -95
5. Canis M, Mage G, Wattiez A, Po uly JL, Bruhat MA The
ovarian endometrioma: why is it so poorly managed?
Laparoscopic treatment of large ovarian endometrioma: why
such a longlearning curve?Hum Reprod 2003 , 18, 5-7
6. Hart RJ , Hickey M, Maouris P, Buckett W. Excisional
surgery vers us ablative surgery for ovarian endometrioma
Cochrane Database 2008 ; 2:CD004992 -CD004992
7.Hachisuga T, Kawaeabayashi T Histopatological analysis of
laparoscopically treated ovarian endometriotic cysts with
special reference to los s of follicles. Hum Reprod 2002, 17,
432-435
8. Maouris P , Brett L.Endometriotic ovarian cysts: the casefor
excisional laparoscopic surgery Gynecol Endocrinol 2002 , 11,
231-234
9. Chapron C, Vercellini P, Barakat H, Viera M and
Dubuisson JB Management of ovarian endometriomas Hum
Reproduc Update 2002, 8 591-597
10. Jones KD and Sutton CJ Pregnancy rates following
ablative laparoscopic surgery for endometriomas Hum
Reprod ., 2002, 17, 782 -785
11. Elisheikh A , Milingos S, Loutradis D, Ka lipolitis G and
Michalas S Endometriosis and reproduc tive disorders Ann N
YAcad S ci., 2003, 997, 247 -254
12. Alborzi S, Momtahan M , Parsanezhad ME, Dehbashi S,
Zolghadri J. Alborzi S A prospective, randomized study
comparing laparoscopic ovarian cystectomy versus
fenestration and coagulation in patients with endometriomas.
Fertil Steril. 2004, 82, 1633 -1637
13. Horace Roman, Solene Quibel, Mathieu Auber, Helene
Musynski,Emmanuel Huet, Loi Marpeau and Jean Jacques
Tuech Reccurrences and fertility after endometrioma ablation
in women with and without colorectal endometriosis, a
prospective cohort study 2014, 30, 558-568

67,85
%
16,8% Dysmenorrhea
Dyspareunia
Rectal pain23,52
%
Figure 4 The most common symptom Figure 3 Rectovaginal Endometriotic Lesion

224