Page 43 - WALS Journal

Nada Abid Al-Hur Al Ebrahimi
is no evidence that this occurs, whereas a recurrence of the excision. 20,28 The other concern is the impact of endometriomata
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endometriomata will inevitably mean further surgery. on artificial reproductive techniques. The European Society
Rectovaginal endometriosis presents surgical challenges for Human Reproduction and Embryology (ESHRE)
because of difficult access and the possibility of injury to the recommends surgery if endometriomata are 4 cm. 23
bowel. Although reported long-term outcomes are encouraging
with advanced laparoscopic techniques, there are few Aim of Study
prospective studies and no randomised controlled trials. 16, 17
One small study of the levonorgestrel intrauterine system in The objective of this review was to determine the most effective
women with rectovaginal endometriosis found improved technique of treating an ovarian endometrioma; either excision
dysmenorrhea, pelvic pain, and dyspareunia after one year. 29 of the cyst capsule or drainage and electrocoagulation of the
A trial comparing estrogen and progesterone combination with cyst wall. The end-points assessed were the relief of pain,
low dose progestogen in 90 women with rectovaginal disease recurrence of the endometrioma, recurrence of symptoms and
reported substantial reductions at 12 months in all types of in women desiring to conceive the subsequent pregnancy rate,
21
pain without major differences between groups. Overall, two either spontaneous or as part of fertility treatment.
thirds of patients were satisfied with this approach.
Material and Methods
Should Women have Hormonal Treatment before The reviewers searched the cochrane menstrual disorders and
Surgery for Endometriosis?
24
subfertility group specialised register of trials, the cochrane
25
Only one study has examined this question. There was no register of controlled trials, medline (1966-august 2007),
26
evidence of a difference in the difficulty of surgery in the women embase and reference lists of articles, the handsearching of
who had received preoperative hormonal treatment. 30 relevant journals and conference proceedings and by the
cochrane menstrual disorders and subfertility group trials
Should Women have Hormonal Treatment after register is based on regular searches of medline.
Conservative Surgery?
Selection Criteria
There was no evidence of improved pain relief with postoperative
hormonal treatment (including danazol, GnRH analogues, oral Randomised controlled trials of excision of the cyst capsule
contraceptives, and medroxyprogesterone acetate) up to 24 versus drainage and electrocoagulation of the cyst in the
11
months after surgery. The studies to date are small, however, management of ovarian endometriomata.
and there is insufficient follow-up to rule out a benefit.
Main Results
What are the Effects of Hormonal Treatment after
Oophorectomy (with or without hysterectomy)? No randomised studies of the management of endometriomata
by laparotomy were found. Two randomised studies of the
There was no evidence of increased rates of recurrence in women laparoscopic management of ovarian endometriomata of greater
who had both ovaries removed and who were given nearly four than 3cm in size, for the primary symptom of pain were included.
years of combined hormone therapy, but the study was Laparoscopic excision of the cyst wall of the endometrioma
underpowered to detect clinically important differences. 22 was associated with a reduced recurrence rate of the symptoms
of dysmenorrhea (OR 0.15 CI 0.06-0.38), dyspareunia (OR 0.08
What is the Impact of Endometriosis on Fertility? CI 0.01-0.51) and non-menstrual pelvic pain (OR 0.10 CI 0.02-
Although management of pain may be the more immediate issue, 0.56), a reduced rate of recurrence of the endometrioma (OR
the long-term outcome of fertility should not be overlooked. 0.41 CI 0.18-0.93) and with a reduced requirement for further
Few studies have examined this. A systematic review of medical surgery (OR 0.21 CI 0.05-0.79) than surgery to ablate the
treatment for women with infertility and endometriosis did not endometrioma. For those women subsequently attempting to
7
find evidence of benefit, and it is not recommended for women conceive it was also associated with a subsequent increased
trying to conceive. 6,23 A systematic review of laparoscopic spontaneous pregnancy rate in women who had documented
treatment of endometriosis in women with subfertility suggested prior sub-fertility (OR 5.21 CI 2.04-13.29). A further randomised
an improvement in pregnancy rate in the 9-12 months after study was identified that demonstrated an increased ovarian
31
surgery. A second systematic review of laparoscopic excision follicular response to gonadotrophin stimulation for women
compared with ablation endometriomata reported a five-fold who had undergone excisional surgery when compared to
19
increase in rate of pregnancy. There is the ongoing concern ablative surgery (WMD 0.6 CI 0.04-1.16). There is insufficient
about ovarian reserve in women who have laparoscopic evidence to favor excisional surgery over ablative surgery with

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