Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Northwestern University Medical School, 333 East Superior Street, Chicago, Illinois 60611, USA
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Abstract |
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Key words: endometrioma/endometriosis/pelvic adhesions/ultrasound-guided drainage
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Introduction |
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Case report |
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At laparoscopy, the pelvis was found to contain extensive adhesive disease with complete obliteration of the posterior cul-de-sac (Figure 2). Both ovaries were densely adherent to the pelvic sidewall, uterus, and colon. The two endometriomas were identified and bilateral ovarian cystectomy with extensive adhesiolysis was performed without complication. Histopathological findings confirmed bilateral ovarian endometriomas. Her post-operative course was unremarkable.
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Note added at proof |
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Discussion |
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Giorlandino et al. (1993) followed 34 patients who underwent ultrasound-guided drainage of endometriomas (Giorlandino et al., 1993): 53% experienced recurrences unrelated to original cyst size, volume aspirated, and pre- or post-treatment with hormonal therapy. No post-procedure complications were reported. Dicker et al. (1991) performed transvaginal drainage of endometriomas in 41 patients who had experienced in-vitro fertilization (IVF) failures (Dicker et al., 1991
). They subsequently achieved significantly higher rates of oocyte retrieval and clinical pregnancy with no discussions of complications or recurrence.
In the current case, de-novo adhesions were documented after attempted transvaginal aspiration of bilateral ovarian endometriomas. We believe that this occurred as a result of peritoneal inflammation from the endometrioma contents. Recently, very high serum CA 125 concentrations were associated with ovarian endometrioma rupture (Johansson et al., 1998). Elevated serum CA 125 concentrations were thought to result from peritoneal mesothelial cell irritation, which resolved following surgical treatment.
It is possible that the pelvic adhesions found at second laparoscopy resulted from an infectious event after the transvaginal drainage or the first laparoscopy. Following both procedures, the patient denied any history of febrile illness or abdominal discomfort. Additionally, she was given antibiotics at the time of her transvaginal drainage to further reduce the risks of infection. Finally, at second laparoscopy there was no evidence of infection or abscess formation, just severe adhesions at the transvaginal drainage needle sites on the ovaries.
Rupturing of the endometriotic cysts without complete evacuation may have put the patient at higher risk of adhesive disease than complete and successful aspiration. If this was the case, then more expedient scheduling of the second laparoscopy might have reduced the formation of adhesions. Unfortunately, there is no way to predict whether transvaginal aspiration of endometriomas will be successful without first attempting such a procedure. By ultrasound, both serosanguineous and viscous cystic fluid appear as a homogeneous unilocular cyst with low level echoes. If ultrasound identifies solid components suggestive of a fibrin clot, then more tenacious material can be expected at the time of transvaginal aspiration.
Ultrasound-guided drainage of endometriomas may have some application in the diagnosis of disease, or in treating those patients who are not good surgical candidates or who have experienced IVF failures. It is considered relatively safe and non-invasive. However, there are associated complications, including abscess formation (Padilla, 1993), recurrence (Aboulghar et al., 1991
; Zanetta et al., 1995
) and the need for subsequent surgery. In this case unsuccessful transvaginal drainage was associated with de-novo pelvic adhesions. Patients with ovarian endometriomas should be advised of the potential for adhesive disease following transvaginal aspiration.
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Notes |
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References |
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Dicker, D., Goldman, J.A., Feldberg, D. et al. (1991) Transvaginal ultrasonic needle-guided aspiration of endometriotic cysts before ovulation induction for in vitro fertilization. J. In vitro Fert. Embryo Transf., 8, 286.[ISI][Medline]
Giorlandino, C., Taramanni, C., Muzii, L. et al. (1993) Ultrasound-guided aspiration of ovarian cysts. Int. J. Gynecol. Obstet. 43, 4144.[ISI][Medline]
Johansson, J., Santala, M. and Kauppila, A. (1998) Explosive rise of serum CA 125 following the rupture of ovarian endometrioma. Hum. Reprod., 13, 35033504.[Abstract]
Monk, B.J., Berman, M.L. and Montz, F.J. (1994) Adhesions after extensive gynecologic surgery: Clinical significance, etiology, and prevention. Am. J. Obstet. Gynecol. 170, 13961403.[ISI][Medline]
Muzii, L., Marana, R., Caruana, P. et al. (1995) Laparoscopic findings after transvaginal ultrasound-guided aspiration of ovarian endometriomas. Hum. Reprod., 10, 29022903.[Abstract]
Padilla, S.L. (1993) Ovarian abscess following puncture of an endometrioma during ultrasound-guided oocyte retrieval. Hum. Reprod., 8, 12821283.[Abstract]
Zanetta, G., Lissoni, A., Valle, C.D. et al. (1995) Ultrasound-guided aspiration of endometriomas: possible applications and limitations. Fertil. Steril., 64, 709713.[ISI][Medline]
Submitted on April 28, 1999; accepted on July 28, 1999.