Michel Canis

The burden of endometriosis: costs and quality of life of women with endometriosis and treated in referral centres

BACKGROUND This study aimed to calculate costs and health-related quality of life of women with endometriosis-associated symptoms treated in referral centres. METHODS A prospective, multi-centre, questionnaire-based survey measured costs and quality of life in ambulatory care and in 12 tertiary care centres in 10 countries. The study enrolled women with a diagnosis of endometriosis and with at least one centre-specific contact related to endometriosis-associated symptoms in 2008. The main outcome measures were health care costs, costs of productivity loss, total costs and quality-adjusted life years. Predictors of costs were identified using regression analysis. RESULTS Data analysis of 909 women demonstrated that the average annual total cost per woman was €9579 (95% confidence interval €8559-€10 599). Costs of productivity loss of €6298 per woman were double the health care costs of €3113 per woman. Health care costs were mainly due to surgery (29%), monitoring tests (19%) and hospitalization (18%) and physician visits (16%). Endometriosis-associated symptoms generated 0.809 quality-adjusted life years per woman. Decreased quality of life was the most important predictor of direct health care and total costs. Costs were greater with increasing severity of endometriosis, presence of pelvic pain, presence of infertility and a higher number of years since diagnosis. CONCLUSIONS Our study invited women to report resource use based on endometriosis-associated symptoms only, rather than drawing on a control population of women without endometriosis. Our study showed that the economic burden associated with endometriosis treated in referral centres is high and is similar to other chronic diseases (diabetes, Crohns disease, rheumatoid arthritis). It arises predominantly from productivity loss, and is predicted by decreased quality of life.

Conservative laparoscopic treatment of 321 ectopic pregnancies

From 1974 to 1984, 321 tubal pregnancies were treated conservatively with laparoscopic techniques. Fifteen cases (4.8%) required a subsequent laparotomy or second laparoscopic procedure because of retained trophoblastic tissue. Of 118 patients desiring subsequent pregnancy, 76 had an intrauterine pregnancy (64.4%) and 26 had a second ectopic pregnancy (22%). Eleven of 24 (45.8%) women attempting conception following conservative laparoscopic removal of an ectopic gestation from the sole remaining fallopian tube established an intrauterine pregnancy. In this same group, seven patients (29.2%) had a second ectopic pregnancy. The fertility results were also analyzed according to the previous history. The postoperative intrauterine pregnancy rate was 85.5% among 62 patients without a history of infertility (group I), compared with 41.1% among 56 patients with a history of infertility or a previous ectopic pregnancy (group II). The subsequent ectopic pregnancy rate in group I was 16.1% versus 28.6% in group II. This large series clearly demonstrates the relative safety and efficacy of conservative laparoscopic treatment of tubal pregnancies.

Second-look laparoscopy after laparoscopic cystectomy of large ovarian endometriomas

Forty-two patients who underwent a second-look laparoscopy after a unilateral or bilateral intraperitoneal cystectomy for treatment of an ovarian endometrioma of greater than 3 cm were included. At second-look laparoscopy, 92.4% of the adnexae treated for a large endometrioma had no deep ovarian endometriosis. Adhesion de novo formation occurred in 21% of the treated adnexae and in 17% of the contralateral adnexae. Complete or partial recurrence of dense adhesions occurred in 82% of the cases. Laparoscopic cystectomy is effective in treating large endometriomas. However, operative difficulties may be encountered, explaining persistent endometriomas and postoperative adhesions.

Prediction of pregnancy in infertile women based on the American Society for Reproductive Medicine's revised classification of endometriosis

OBJECTIVE To estimate the empirical relationship between the revised American Society for Reproductive Medicines classification of endometriosis and pregnancy rates after treatment. DESIGN Retrospective analysis. PATIENT(S) Patients seen by four practicing physicians. INTERVENTION(S) Medical and/or surgical therapy for endometriosis. MAIN OUTCOME MEASURE(S) Pregnancy defined as ongoing or delivered. RESULT(S) There were no significant differences in pregnancy rates across stages of endometriosis. There was a slight decline in pregnancy rates among patients with Stage IV endometriosis, but statistical significance was not achieved. CONCLUSION(S) The use of an arbitrary weighted system for assigning scores to individual categories of disease, or for computing a total score, has limited the overall effectiveness of the classification system to predict pregnancy.

Laparoscopic management of adnexal masses: a gold standard?

PURPOSE OF REVIEW To review recent literature on the laparoscopic management of adnexal masses, when this approach may be considered as a gold standard. RECENT FINDINGS Cyst rupture was recently demonstrated to be a significant prognostic factor in stage I invasive epithelial carcinoma, and it was recommended to restrict the laparoscopic approach to patients with preoperative evidence that the cyst was benign. The laparoscopic approach is still highly controversial in masses suspicious at ultrasound. The limits of the laparoscopic approach are discussed reviewing recent literature and our experience. The laparoscopic management of adnexal masses appears to be safe in most hospitals even in developing countries. This approach is being used with increasing frequency in unusual indications such as newborns, children, adolescents and pregnant women. The learning curve for endoscopic surgery appears to be longer than expected. Many patients with benign adnexal masses, such as ovarian endometrioma, are still treated by laparotomy or with an inadequate endoscopic technique. Several studies have suggested that the stripping technique is a tissue-sparing procedure. SUMMARY The laparoscopic puncture of malignant ovarian tumours confined to the ovaries is uncommon, and should be avoided whenever possible. The teaching of endoscopy is essential to promote adequate procedures performed according to the principles of microsurgery and to preserve postoperative ovarian physiology.

Laparoscopic management of adnexal masses suspicious at ultrasound

Objective To evaluate the laparoscopic management of adnexal masses suspicious at ultrasound. Methods In a prospective study, adnexal masses suspicious at ultrasound were managed by laparoscopy. Indications for laparotomy included general contraindications to laparoscopy, obviously disseminated ovarian cancer, and technically impossible laparoscopic treatment. After laparoscopic diagnosis, frozen sections were used to confirm a diagnosis of malignancy. Treatment was performed by laparoscopy whenever feasible. Results Over a 3-year period, 247 of the 599 adnexal masses (41.2%) treated in our department were suspicious or solid at ultrasound. Seventeen patients were evaluated by laparotomy and 230 by laparoscopy. Overall, 204 women (82.6%) were treated by laparoscopy, including seven of the 37 malignant tumors (18.9%) and 197 of the 210 benign masses (93.8%). One case of tumor dissemination occurred after a laparoscopic adnexectomy and morcellation of a grade 1 immature teratoma. Conclusion Laparoscopic diagnosis of adnexal masses suspicious at ultrasound avoids many laparotomies for the treatment of benign masses and allows an improved inspection of the upper abdomen. The laparoscopic treatment of adnexal masses suspicious at surgery should be evaluated further in carefully designed prospective studies.

Expression of estrogen receptor alpha and beta in peritoneal and ovarian endometriosis

OBJECTIVE To quantify and compare messenger RNA (mRNA) levels of ER-alpha and ER-beta among ovarian endometriotic cysts and red and black peritoneal endometriotic lesions. DESIGN Prospective study. SETTING University hospital. PATIENT(S) Patients with or without endometriosis. INTERVENTION(S) Samples of peritoneal (n = 33) and ovarian endometriotic lesions (n = 37) were obtained during laparoscopic surgery. Normal eutopic endometrial tissues and macroscopically normal peritoneal tissues were obtained as controls during or just after surgery. MAIN OUTCOME MEASURE(S) Expression of mRNA for ER-alpha and ER-beta, using a real-time reverse transcription (RT)-PCR assay, TaqMan RT-PCR, and nonradioactive in situ hybridization (ISH) techniques. RESULT(S) Both eutopic endometrium and endometriotic tissues showed predominantly higher levels of ER-alpha than ER-beta mRNA. Relative ratio of ER-alpha to ER-beta (ER-alpha/ER-beta) mRNA in red peritoneal lesions was significantly higher than in black lesions and ovarian endometriotic cysts. There was no significant difference in ER-alpha/ER-beta between proliferative eutopic endometrium and red peritoneal lesions. These results were confirmed by ISH analysis, which also revealed that the two estrogen receptors were localized in both epithelial and stromal cells of endometriotic tissues. CONCLUSION(S) The predominant expression of ER-alpha in both glandular epithelial and stromal cells may be essential for the development and growth of peritoneal and ovarian endometriosis.

Multifactorial analysis of fertility after conservative laparoscopic treatment of ectopic pregnancy in a series of 223 patients

OBJECTIVES To lay down the criteria to clearly define whether conservative or radical laparoscopic treatment should be adopted in cases of ectopic pregnancies (EP). DESIGN Retrospective, noncomparative. SETTING At the University Hospital of Clermont Ferrand and the La Pergola Clinic at Vichy from July 1974 to December 1987. PATIENTS This study was carried out in 223 patients who had been treated laparoscopically for EP and who desired future childbearing and who were not lost to follow-up. MAIN OUTCOME MEASURES The measures chosen to achieve the objective included age, parity, size of hematosalpinx, volume of hemoperitoneum, tubal rupture, location, intrauterine device, ipsilateral and contralateral adhesions, and patients previous history of salpingitis, EP, solitary tube, and tubal infertility. RESULTS The general intrauterine pregnancy rate was 67% (149 patients) and the recurrence rate 12% (27 patients). The results according to the studied factors demonstrated that age, parity, and the type of the EP have no influence on the postectopic fertility. The history of the patient, ipsilateral adhesions, or contralateral tubal status significantly reduce the future fertility prognosis and risk of recurrence. CONCLUSIONS From a multivariable analysis, the authors propose a scoring system to choose the most suitable treatment to preserve fertility and to reduce the risk of recurrence ranging from laparoscopic conservative treatment to laparoscopic salpingectomy with contralateral sterilization.

Laparoscopic distal tuboplasty: report of 87 cases and a 4-year experience.

OBJECTIVE To evaluate fertility results after laparoscopic distal tuboplasty and to compare these results with those obtained previously with microsurgery. DESIGN Retrospective, nonrandomized. SETTING Department of Obstetrics and Gynecology at the University Hospital of Clermont-Ferrand, France. PATIENTS All the distal tuboplasties performed between October 1985 and June 1989 were included. Adnexal damage was assessed using tubal and adhesions scoring systems described previously. Tuboplasty was carried out bilaterally except when one tube was absent or severely damaged (tubal stage III or IV and/or with severe adhesions). Patients with bilateral severe adnexal damages were treated only if they refused to undergo in vitro fertilization. Laparoscopic tuboplasty was performed either with the CO2 laser or with conventional instruments. MAIN OUTCOME MEASURE Fertility after laparoscopic treatment was evaluated using simple and cumulative pregnancy rates (PRs) according to the adnexal damage and compared with the microsurgical results using PRs according to the adnexal damage. RESULTS The overall intrauterine and extrauterine PRs were 33.3% and 6.9%, respectively. Twenty-six of the 29 intrauterine pregnancies were obtained within the 1st postoperative year. According to tubal and adhesion stages, the results of laparoscopic distal tuboplasty are similar to those obtained using microsurgery. CONCLUSION We conclude that laparoscopic distal tuboplasty, when performed by experienced surgical laparoscopists, represents an effective alternative to microsurgery.

Impaired Down-Regulation of E-Cadherin and β-Catenin Protein Expression in Endometrial Epithelial Cells in the Mid-Secretory Endometrium of Infertile Patients with Endometriosis

CONTEXT Only a few, small, human studies on E-cadherin and beta-catenin expression in normal cycling human endometrium have been reported. It remains unclear whether expression of these molecules might be altered in the endometrium of infertile patients with endometriosis. OBJECTIVES The aim of the present study was to investigate E-cadherin and beta-catenin expression in the endometrium of infertile patients with endometriosis, those with uterine fibromas, and patients with unexplained infertility. DESIGN Expression levels of E-cadherin and beta-catenin mRNA and/or protein in the endometrium of infertile patients with endometriosis (n = 151), those with uterine fibromas (n = 41), patients with unexplained infertility (n = 9), as well as healthy fertile controls (n = 57) were measured. This study utilized laser capture microdissection, real-time RT-PCR, and immunohistochemistry. RESULTS No significant differences in E-cadherin or beta-catenin mRNA expression in microdissected epithelial cells were observed among the different groups throughout the menstrual cycle. However, very low or no protein expression of E-cadherin, total beta-catenin, or dephosphorylated beta-catenin in luminal and glandular epithelial cells was detected in the mid-secretory endometrium of healthy fertile controls. E-cadherin, total beta-catenin, and dephosphorylated beta-catenin protein expression in the mid-secretory endometrium of infertile patients with endometriosis or unexplained infertility was significantly higher compared to that of healthy fertile controls in both luminal and glandular epithelial cells. CONCLUSIONS These findings suggest that impaired down-regulation of E-cadherin and beta-catenin protein expression, along with Wnt/beta-catenin signaling pathway activation during the window of implantation, might be one of the potential molecular mechanisms of infertility in patients with endometriosis.