Raffaella Daguati

Postoperative oral contraceptive exposure and risk of endometrioma recurrence

OBJECTIVE The purpose of this study was to compare the postoperative risk of endometrioma recurrence in women using oral contraception and in those undergoing simple observation. STUDY DESIGN After laparoscopic excision of ovarian endometriotiomas, a cyclic, low-dose, monophasic oral contraceptive pill (OCP) was offered to women not seeking pregnancy. One month after surgery, and every 6 months afterward, the patients underwent clinical and ultrasonographic assessment. RESULTS Of the 277 patients who entered the study, 102 used OCP for the entire follow-up period (always users), 129 used OCP discontinuously (ever users), and 46 declined treatment (never users). The median follow-up was 28 months. Recurrent endometriotic cysts were detected in 74 subjects (27%). The 36-month cumulative proportion of subjects free from endometrioma recurrence was 94% in the always users compared with 51% in the never users (P < .001); adjusted incidence rate ratio (IRR) = 0.10 (95% CI, 0.04-0.24). CONCLUSION Regular postoperative use of OCP effectively prevents endometrioma recurrence.

The second time around: reproductive performance after repetitive versus primary surgery for endometriosis

After repetitive surgery for recurrent endometriosis, 20 of 89 (22%) women achieved spontaneous pregnancy, compared with 165 of 411 (40%) after first-line procedure (adjusted incidence rate ratio, 0.51; 95% confidence interval, 0.32 to 0.82), and the 12- and 24-month cumulative pregnancy rates were 14% and 26% in the former group compared with 32% and 38% in the latter. Among infertile patients at baseline, 13 of 67 (19%) conceived after reoperation compared with 98 of 290 (34%) after primary surgery (adjusted incidence rate ratio, 0.55; 95% confidence interval, 0.30 to 0.99), and the 12- and 24-month cumulative pregnancy rates were 13% and 22% in the former group and 25% and 30% in the latter.

Evidence for asymmetric distribution of lower intestinal tract endometriosis.

The aetiology of endometriosis is controversial. Investigating the anatomical distribution of endometriotic lesions may provide insights into the pathogenesis of the disease. If ectopic endometrium is due to retrograde menstruation, the pattern of lesions should be determined mainly by anatomical and physiological variables, whereas if coelomic metaplasia is the cause of endometriosis, lesions should not be distributed in relation to factors influencing the spreading and implantation of endometrial cells. The pattern of involvement of bilateral and symmetric pelvic organs has been studied specifically to verify whether endometriotic lesions are equally distributed on the two sides. In this regard, it has been demonstrated that the left ovary, ureter, and uterosacral ligament, as well as the right inguinal canal structures and sciatic nerve are affected significantly more frequently than the contralateral corresponding organ. – 12 This preference for the left side constitutes indirect evidence against the coelomic metaplasia theory, which is more likely to be associated with equal distribution, and the laterality has been attributed to the presence of the sigmoid colon on the left hemipelvis. – 12 The lower intestinal tract is the most common site of extragenital endometriosis. This is not unexpected, given its proximity to the fallopian tubes. However, if the menstrual reflux theory is true, the left terminal colon should be affected more frequently than the right one. In fact, the sigmoid is in close contiguity to the ipsilateral tube and creates a sort of shelter which should facilitate implantation of regurgitated endometrial cells, whereas the caecum is more cranial and hence less prone to be involved. It has been observed that endometriotic lesions of the descending colon are more common than those of the ascending colon, but the issue has never been approached formally. Moreover, the evidence in this regard is confusing, because endometriosis of the rectal tract is often considered among lesions of the left side. This may not be true, as the relatively frequent involvement of the rectum could originate from implants in the pouch of Douglas and be considered a primarily midline lesion. Finally, deep, infiltrating and obstructive lesions were not always distinguished from superficial, non-obstructing implants. To verify the hypothesis of an asymmetrical distribution of endometriotic lesions of the ileocaecum and colon, we reviewed all data published on the topic in the Englishlanguage scientific literature in the last two decades. A detailed description of the patients’ symptoms and signs and of the diagnostic and treatment alternatives was not among the aims of the study.

The use and effectiveness of in vitro fertilization in women with endometriosis: the surgeon's perspective

OBJECTIVE To assess the use and effectiveness of IVF in a cohort of women undergoing surgery for endometriosis. DESIGN Cohort study. SETTING University hospital. PATIENT(S) Four hundred thirty-eight patients who attempted to become pregnant after conservative surgery for endometriosis. INTERVENTION(S) Interview. MAIN OUTCOME MEASURE(S) Pregnancy and IVF use. RESULT(S) One hundred ninety-four women conceived in vivo (44%). One hundred twenty-four women did not undergo IVF despite their infertility status (51% of the group of women who failed to conceive in vivo). One hundred thirty-nine women underwent at least one IVF attempt. The cumulative rate of IVF use at 36 months of infertility was 33%. The live-birth/ongoing pregnancy rate per started cycle and per patient was 10% and 20%, respectively. CONCLUSION(S) In a large tertiary care and referral center, IVF played only a minor role in the treatment of endometriosis-associated infertility.

Effect of delaying post-operative conception after conservative surgery for endometriosis

The objective of this study was to determine whether delaying attempts to conceive after surgery for endometriosis impacts on reproductive prognosis. Patients operated on for endometriosis who were not seeking pregnancy at the time of surgery were selected (n=124) from a large survey regarding reproductive outcome of women with the disease. Pregnancy rate and rate of second surgery were compared between women who attempted conception within 12 months after surgery (n=61) and those compared who postponed attempts for 12 months or more (n=63). In women delaying attempted conception, the adjusted incidence rate ratio for pregnancy and repetitive surgery was 0.79 (95% CI 0.46-1.35) and 1.70 (95% CI 0.86-3.38), respectively. In conclusion, attempting conception shortly after surgery appears advisable since delaying is associated with a lower pregnancy rate and a higher rate of recurrence. However, these differences did not reach statistical significance and this advice is thus not mandatory. Larger studies are warranted to validate these conclusions.