Service de Chirurgie Gynécologique, Clinique Universitaire Baudelocque, C.H.U.Cochin Port-Royal, 123 Bld Port-Royal, 75014 Paris, France
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Abstract |
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Key words: endometriosis/infertility/operative laparoscopy/uterosacral ligaments
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Introduction |
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Materials and methods |
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The fertility study was carried out for those patients who complied with the following inclusion criteria: aged >20 years and <40 years; infertility was defined as at least 12 months of unprotected intercourse without resulting in pregnancy (Marcoux et al., 1997); positive histological result; no associated infertility factors (tubal patency at preoperative hysterosalpingography); no associated male infertility. The spermogram was considered to be normal if the following three parameters were satisfactory: sperm count >20x106/ml; >30% motility and >50% normal morphology (Adamson et al., 1993
).
The patients were seen in consultation every 4 months for the first year after operation and then every 6 months. Fertility was studied globally and also as a function of each of the following parameters: woman's age, parity, body mass index (BMI), duration of infertility, a past history of endometriosis, the rAFS score (AFS, 1985), the duration of the operation, the necessity or not of associated pelvic adhesiolysis and/or intraperitoneal cystectomy with resection of the deep endometriotic lesions infiltrating the USL, and the existence or not of pre- or post-operative medical treatment.
Data are presented as mean ± SD. The crude probabilities of pregnancies were calculated by using KaplanMeier survival analysis (Kaplan and Meier, 1958). The starting point for life-table calculations was the date of the operative laparoscopy. The end point was the date pregnancy began (worked out by early ultrasound examination at 10 weeks of amenorrhoea) or last contact if not pregnant (contact by mail in January 1997). Differences between groups were analysed for significance by the Fisher exact test and the MannWhitney U-test. P < 0.05 was considered to be significant.
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Results |
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The mean age of the 30 patients complying with the inclusion criteria was 31 ± 4.7 years (range 2040). The infertility was primary in 14 cases (46.7%) and secondary in 16 cases (53.3%). The mean duration of infertility was 35 ± 18.6 months (range 1385). Mean parity for the patients was 0.3 ± 0.65 (range 03). A total of 24 patients (80%) were nulliparous. In all, 24 patients (80%) were nulliparous. The average weight of patients was 58 ± 10.5 kg (range 4996). Their average height was 165 ± 7.2 cm (range 150170). Their BMI was 21 ± 3 kg/m2 (range 1731). Of these patients, 25 (83.3%) presented with painful pelvic symptoms associated with their infertility. The types of pain, sometimes more than one in the same patient, were the following: dysmenorrhoea (22 cases); deep dyspareunia (18 cases); chronic pelvic pain (eight cases). A total of 11 patients (36.7%) had already undergone one or more surgical procedures (range 16) for endometriosis in another establishment. The clinical examination data were the following: in eight cases (26.7%) there was a palpable nodule on the USL; in 12 cases (40.0%) the USL were tense and/or infiltrated but had no palpable nodule; in 10 cases (33.3%) the USL appeared clinically normal. For these 10 patients the indication for laparoscopy was chronic pelvic pain associated with infertility. For these 10 patients who presented with functional pain symptoms, laparoscopic resection of the USL was carried out due to finding at laparoscopy of peritoneal retraction, induration and/or asymmetry of the USL amongst other indications (Chapron et al., in press).
The mean duration of the operation was 119 ± 57.7 min (range 45290). The mean rAFS score was 22 ± 20.6 (range 480). Distribution of the patients according to the rAFS classification (AFS, 1985) was the following: stage I: three cases (10.0%); stage II: 14 cases (46.7%); stage III: eight cases (26.6%); stage IV: five cases (16.7%). Half the patients had a rAFS score of less than 13. Resection of the USL was bilateral in nine cases (30.0%). When resection was unilateral (21 cases; 70.0%) the lesions were more often located on the left (n = 14) than the right (n = 7) (P = 0.007). The following laparoscopic surgery procedures, sometimes more than one in the same patient, were associated with resection of the USL: adnexal adhesiolysis (18 cases; 60.0%); intraperitoneal cystectomy (five cases; 16.7%); bipolar coagulation of superficial peritoneal endometriotic lesions (23 cases; 76.7%); ureterolysis (22 cases; 73.3%) and dissection of the lateral rectal fossa (10 cases; 33.3%).
The overall intrauterine pregnancy (IUP) rate, including births and miscarriages, was 50.0% (15 patients). A total of 11 IUP occurred spontaneously. Three patients were pregnant with the use of ovulation induction, following dysovulation associated with endometriosis. One pregnancy was achieved after in-vitro fertilization (IVF). Of these 15 IUP, 12 patients gave birth normally at term, and three had an early miscarriage. None of the patients had an ectopic pregnancy. We recommend that patients who do not become pregnant after 1 year following intervention should undergo IVF.
The cumulative pregnancy rate for the 14 IUPs obtained without IVF was 48.5% at 12 months (95% confidence interval 28.368.7) (Figure 1). The average time before these IUP occurred was 7 ± 5.8 months (range 120). Half the patients were pregnant within 6 months after the operation. The IUP rate obtained without IVF was not correlated in statistically significant fashion with the rAFS classification (AFS, 1985). Whereas the IUP rate obtained without IVF was 47.0% (eight cases) for patients presenting stage I or II endometriosis, it was 46.1% (six cases) for patients with stage III or IV endometriosis (not significant) (Table I
).
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Discussion |
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The USL are one of the most frequent locations for deep endometriosis (Cornillie et al., 1990). Medical treatments are more often purely palliative (Wingfield and Healy, 1993
) and the treatment of choice for patients with deep endometriosis is surgery (Koninckx and Martin, 1995
). In order to be effective with regard to pain it is necessary during the laparoscopic procedure to resect all of the deep endometriotic lesions infiltrating the USL. This treatment requires extensive dissection and ureterolysis for some patients (73.3% of cases in this series) and/or dissection of the lateral rectal fossa (33.3% of cases in this series).
The fertility results found in this study after operative laparoscopic treatment of deep endometriosis infiltrating the USL are encouraging (Figure 1). These results are interesting when deciding on the strategy to use for infertile patients presenting with deep endometriotic lesions. For the patients in this series, none of whom had other infertility factors apart from the deep endometriosis infiltrating the USL, the laparoscopic surgery treatment enabled 47.6% of them (14/30) to become pregnant without having to use IVF. These results match those of Reich et al. (1991) who, in a series of 100 women with cul-de-sac obliteration secondary to retrocervical deep endometriosis treated by operative laparoscopy, had a 70% (32/46) viable intrauterine pregnancy rate among patients with infertility. Although these results are satisfactory, this does not mean that it can be stated that the deep endometriotic lesions were the only lesions responsible for the infertility these patients suffered from. During the operation, in addition to resecting the deep lesions, all the other associated endometriotic lesions were treated. However these results do show that it is logical in this context to associate the standard treatment for endometriosis (e.g. lysis, i.p. cystectomy, bipolar coagulation of superficial peritoneal endometriotic lesions) with resection of deep endometriotic lesions infiltrating the USL. There are two arguments in favour of this attitude. Firstly, apart from the benefit in terms of pregnancy, which is comparable to that reported in other publications (Adamson et al., 1993
; Marcoux et al., 1997
), resection of the deep endometriotic lesions means that the patients, who in most cases present with pelvic pain, find that the pain symptoms are significantly reduced in 75% of cases (Chapron et al., 1998a
). Secondly, one third of the patients in this study had already undergone one or more surgical procedures in connection with this infertility, during which exeresis of the deep endometriotic lesions had not been carried out.
The fertility results were not correlated with the rAFS Classification (AFS, 1985) (Table I). The fertility results observed for patients with stage I and II endometriosis fit in with the conclusions drawn by Marcoux et al. (1997)
who, in a controlled multicentre trial, demonstrated that laparoscopic resection or ablation of minimal and mild endometriosis enhances fecundity in infertile women. The fact that the rAFS classification (AFS, 1985) is not a sensitive predictor of pregnancy following treatment has been reported by other authors (Adamson and Pasta, 1994
; Guzick et al., 1997
). Although this classification at least enables gynaecologists to adopt a common staging system, it is not perfect. Changes following a period of careful consideration would seem to be essential (Dubuisson and Chapron, 1994
). The fact that the fertility results for patients who present little if any anatomical alterations (stages I and II according to the rAFS classification) are not significantly different from those of patients who had stage III or IV endometriosis confirms that factors other than purely anatomical impairment must be involved in order to explain the influence of endometriosis on fertility. Certain authors have suggested that the morphological appearance of implants and certain biomarkers (e.g. CA-125) may affect infertility (Vernon et al., 1986
; Lessey et al., 1994
; Pittaway et al., 1995
).
These preliminary results are interesting. For infertile patients presenting with deep endometriosis infiltrating the USL without any other cause of infertility, complete operative laparoscopic treatment of endometriosis enables a spontaneous IUP rate of 46.7% to be obtained. These results mean that these patients can be offered operative laparoscopic treatment, during which extensive retroperitoneal dissection may be carried out, enabling half of the patients to become pregnant. In other words, extensive laparoscopic surgery procedures in this context would not seem to adversely affect fertility. Further studies are essential in order to confirm these preliminary results, and also achieve a better understanding of the physiopathology of endometriosis with respect to infertility.
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Notes |
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References |
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Submitted on May 12, 1998; accepted on October 29, 1998.