RESUMEN
BACKGROUND: There is a growing consensus that ovarian reserve is reduced after surgical excision of ovarian endometriomas. However, it remains to be fully clarified whether this damage precedes or follows surgery. In order to further elucidate this aspect, we evaluated ovarian responsiveness to hyperstimulation in women selected for IVF with unilateral unoperated endometriomas. The main aim of this study was to compare the number of developing follicles in the affected ovary with that in the contralateral intact gonad as a control. METHODS: Patients selected for IVF who were diagnosed with one or more monolateral endometriomas (diameter <4 cm) and who did not undergo previous ovarian surgery were retrospectively identified. We compared the number of follicles (diameter ≥ 11 mm) and the number of co-dominant follicles (diameter >15 mm) on the day of hCG administration in the affected and intact ovaries. RESULTS: Among the 84 women selected, the median interquartile range (IQR) number of follicles ≥ 11 mm in the affected and intact ovaries was 5 (3-7) and 5 (3-8), respectively (P= 0.36). The median (IQR) number of co-dominant follicles in the affected and intact ovaries was 3 (2-4) and 3 (2-5), respectively (P= 0.48). The number of co-dominant follicles was lower in the affected ovary in 36 cases (43%, 95% confidence interval: 32-53%). We also failed to identify any statistically significant difference between the two ovaries when evaluating data according to the number of cysts, their dimension, the dose of gonadotrophins used or the number of oocytes retrieved. CONCLUSIONS: In women selected for IVF, the presence of an endometrioma does not markedly affect responsiveness to hyperstimulation.
Asunto(s)
Endometriosis/fisiopatología , Folículo Ovárico/fisiología , Inducción de la Ovulación , Adulto , Endometriosis/cirugía , Femenino , Humanos , Enfermedades del Ovario/cirugía , Ovario/fisiología , Estudios RetrospectivosRESUMEN
OBJECTIVE: This study was undertaken to ascertain whether the incidence of pregnancy is increased and time-to-conception is reduced in infertile women with rectovaginal endometriosis undergoing conservative surgery compared with those on expectant management. STUDY DESIGN: A total of 105 infertile women under the age of 40 years with rectovaginal endometriosis and no other associated major infertility factor underwent first-line conservative surgery at laparotomy or expectant management according to a shared decision-making approach. RESULTS: Among the 44 women who had resection of rectovaginal endometriosis, 15 became pregnant, compared with 22 of the 61 women who choose expectant management (24-month cumulative probabilities, 44.9% and 46.8%, respectively; log-rank test, chi2(1) = 0.75; P = .38). One major and 9 minor postoperative complications occurred. Significant differences in pain-free survival time in favor of the surgery group were observed for dysmenorrhea, dyspareunia, and dyschezia. CONCLUSION: Conservative surgery for rectovaginal endometriosis in infertile women does not modify the reproductive prognosis although it does increase pain-free survival time.
Asunto(s)
Endometriosis/cirugía , Procedimientos Quirúrgicos Ginecológicos , Infertilidad Femenina/fisiopatología , Enfermedades del Recto/cirugía , Reproducción , Enfermedades Vaginales/cirugía , Adulto , Endometriosis/complicaciones , Femenino , Humanos , Infertilidad Femenina/complicaciones , Cuidados Paliativos , Embarazo , Índice de Embarazo , Pronóstico , Enfermedades del Recto/complicaciones , Análisis de Supervivencia , Enfermedades Vaginales/complicacionesRESUMEN
OBJECTIVE: To evaluate the efficacy, safety, and tolerability of an estrogen-progestogen combination versus low-dose norethindrone acetate in the treatment of persistent pain after surgery for symptomatic rectovaginal endometriosis. DESIGN: Randomized controlled trial. SETTING: Academic center. PATIENT(S): Ninety women with recurrent moderate or severe pelvic pain after unsuccessful conservative surgery for symptomatic rectovaginal endometriosis. INTERVENTION(S): Twelve-month, continuous treatment with oral ethinyl E2, 0.01 mg, plus cyproterone acetate, 3 mg/day, or norethindrone acetate, 2.5 mg/day. MAIN OUTCOME MEASURE(S): Degree of satisfaction with therapy. RESULT(S): Seven women in the ethinyl E2 plus cyproterone acetate arm and five in the norethindrone acetate arm withdrew because of side effects (n=5), treatment inefficacy (n=6), or loss to follow-up (n=1). At 12 months, dysmenorrhea, deep dyspareunia, nonmenstrual pelvic pain, and dyschezia scores were substantially reduced without major between-group differences. Both regimens induced minor unfavorable variations in the serum lipid profile. According to an intention-to-treat analysis, 28 (62%) out of 45 patients in the ethinyl E2 plus cyproterone acetate group and 33 (73%) out of 45 in the norethindrone acetate group were satisfied with the treatment received. CONCLUSION(S): Low-dose norethindrone acetate could be considered an effective, tolerable, and inexpensive first-choice medical alternative to repeat surgery for treating symptomatic rectovaginal endometriotic lesions in patients who do not seek conception.
Asunto(s)
Endometriosis/tratamiento farmacológico , Terapia de Reemplazo de Estrógeno/métodos , Estrógenos/administración & dosificación , Noretindrona/análogos & derivados , Progestinas/administración & dosificación , Enfermedades del Recto/tratamiento farmacológico , Enfermedades Vaginales/tratamiento farmacológico , Adolescente , Adulto , Intervalos de Confianza , Quimioterapia Combinada , Endometriosis/patología , Femenino , Humanos , Persona de Mediana Edad , Noretindrona/administración & dosificación , Acetato de Noretindrona , Dimensión del Dolor/efectos de los fármacos , Enfermedades del Recto/patología , Estadísticas no Paramétricas , Enfermedades Vaginales/patologíaRESUMEN
OBJECTIVE: To ascertain whether long-term reduction of pain is obtained by continuous administration of an oral contraceptive (OC) in women with endometriosis-associated recurrent dysmenorrhea that does not respond to cyclic OC use. DESIGN: Prospective, therapeutic, self-controlled clinical trial. SETTING: A tertiary care and referral center for patients with endometriosis. PATIENT(S): Fifty women who underwent surgery for endometriosis in the previous year and experienced recurrent dysmenorrhea despite cyclic OC use. INTERVENTION(S): Continuous use of an OC containing ethinyl estradiol (0.02 mg) and desogestrel (0.15 mg) for 2 years. MAIN OUTCOME MEASURE(S): Dysmenorrhea variation during cyclic and continuous OC use, evaluated with a 100-mm visual analog scale and a 0- to 3-point verbal rating scale, and degree of satisfaction with continuous OC treatment. RESULT(S): In the study period, amenorrhea, spotting, and breakthrough bleeding were reported by 19 (38%), 18 (36%), and 13 (26%) women. The mean +/- SD number of >7-day bleeding episodes with consequent 7-day OC suspension was 5.5 +/- 2.1. The mean +/- SD dysmenorrhea visual analog scale and verbal rating scale scores were 75 +/- 13 and 2.4 +/- 0.5 at baseline and 31 +/- 17 and 0.7 +/- 0.6 at 2-year follow-up, respectively. Moderate or severe side effects were reported by 7/50 (14%) women. At final evaluation, 13 (26%) women were very satisfied, 27 (54%) were satisfied, 1 (2%) was uncertain, 8 (16%) were dissatisfied, and 1 (2%) was very dissatisfied. CONCLUSION(S): Long-term continuous OC use can be proposed to women with symptomatic endometriosis and menstruation-related pain symptoms.
Asunto(s)
Anticonceptivos Orales Combinados/uso terapéutico , Desogestrel/uso terapéutico , Dismenorrea/tratamiento farmacológico , Dismenorrea/etiología , Endometriosis/complicaciones , Congéneres del Estradiol/uso terapéutico , Etinilestradiol/uso terapéutico , Congéneres de la Progesterona/uso terapéutico , Adulto , Anticonceptivos Orales Combinados/efectos adversos , Desogestrel/efectos adversos , Dismenorrea/fisiopatología , Congéneres del Estradiol/efectos adversos , Etinilestradiol/efectos adversos , Femenino , Humanos , Dimensión del Dolor , Satisfacción del Paciente , Congéneres de la Progesterona/efectos adversos , Estudios Prospectivos , RetratamientoRESUMEN
The quality of the evidence that supports the use of medical treatment before conservative surgery for endometriosis is manifestly poor, and no recommendations can be made based on the results of the published studies. There are practical advantages inherent to this schedule, but whether this translates into better conception rates and reduced pain recurrence rates is unproven. The effect of drug therapy after surgery can be assessed better as data from seven true randomized, controlled trials are available. The results of the current review do not support the notion that suppressing ovarian activity postoperatively increases the long-term pregnancy rate. As far as pelvic pain is concerned, more data are needed to verify the reduced symptoms recurrence rate found in four trials in women who were allocated to postoperative medical therapy, particularly in view of the different results obtained in some of the considered studies. The observed differences among various drugs used before or after surgery are limited in clinical terms and, in the absence of formal randomized comparisons, are difficult to interpret. Because of their tolerable side effects and limited cost, progestins with or without estrogens should be considered strongly as first-line postoperative medical treatment if and when suppression of ovulation after conservative surgery is deemed opportune.