Clinical efficacy of dienogest against endometriomas with a maximum diameter of ≥4 cm.

OBJECTIVE: This prospective observational study aims to demonstrate the clinical efficacy of dienogest in treating endometriomas with a maximum diameter of ≥4 cm. METHODS: Patients (n = 81) with endometriomas (diameter of ≥4 cm) were enrolled and administered orally with dienogest (2 mg daily) and followed up for a year [Ethical approval code: 2020 Research 343]. Further, the efficacy was determined by recording the largest diameter and volume of the endometriomas, uterine volume, endometrial thickness, and the largest diameter of uterine fibroids in the patients during 0, 6, and 12 months. The pain symptoms were assessed using the Numerical Rating Scale (NRS), and the side effects of medication were monitored. With the consent, some patients underwent routine blood tests, and serum hormone, as well as Anti-Müllerian Hormone (AMH) levels were measured. RESULTS: The dienogest treatment resulted in a significant reduction of the maximum diameter of these cysts from 50.5 mm to 41 mm in 6 months and 34 mm in 12 months. In addition, the volume of the cysts significantly decreased from 37.8 ml from baseline to 18.5 ml in 6 months and 11.8 ml in 12 months. Among 26 subjects with ultrasonic signs of endometrial polyps, 92.3% of cases displayed no polyps after 12 months. No significant changes were observed in the size of uterine fibroids and AMH levels. The NRS score showed a decrease from an average of 6.6-1.2 in 12 months. CONCLUSION: Dienogest could effectively reduce the diameter and volume of endometriomas with a maximum diameter of ≥4 cm, improving anemia, as well as pain symptoms and preserving ovarian function.

Association between Ovarian Endometriomas and Stage of Endometriosis.

Objectives: To determine the association between ovarian endometriomas and stage of endometriosis. Methods: A total of 222 women aged 18-55 years old, who underwent minimally invasive surgery between January 2016 and December 2021 for treatment of endometriosis were included in the study. Patients underwent laparoscopic and/or robotic treatment of endometriosis by a single surgeon (FRN) and were staged using the ASRM revised classification of endometriosis. Pre-operative imaging studies, and operative and pathology reports were reviewed for the presence of endometriomas and the final stage of endometriosis. Using univariate analyses for categorical variables and the two-sample t-test or Mann-Whitney test for continuous data, association between endometriomas, stage of endometriosis, type of endometrioma, and other patient parameters such as age, gravidity, parity, laterality of endometriomas, prior medical treatment, and indication for surgery was analyzed. Results: Of the 222 patients included in the study, 86 patients had endometrioma(s) and were found to have stage III-IV disease. All 36 patients with bilateral endometriomas and 70% of patients with unilateral endometriomas had stage IV disease. Conclusions: The presence of ovarian endometrioma(s) indicates a higher stage of disease, correlating most often with stage IV endometriosis. Understanding the association between endometriomas and anticipated stage of disease can aid in appropriate pre-operative planning and patient counseling.

Genetic alteration of mRNA editing enzyme APOBEC3B in the pathogenesis of ovarian endometriosis.

RESEARCH QUESTION: What are the specific genetic alterations and associated network in endometriotic cells responsible for the disease pathogenesis? DESIGN: Case control experimental study involving 45 women with endometriosis who underwent laparoscopic surgery (case) and 45 normal samples from women undergoing total abdominal hysterectomy (control). The endometrial samples were subjected to whole exome sequencing (WES) of endometriotic tissue and copy number variation analysis. Validation of gene hits were obtained from WES using polymerase chain reaction techniques, immunological techniques, in-silico tools and transgenic cell line models. RESULTS: Germline heterozygous deletion of mRNA editing enzyme subunit APOBEC3B was identified in about 96% of endometriosis samples. The presence of germline deletion was confirmed with blood, endometrium and normal ovary samples obtained from the same patient. APOBEC3B deletions resulted in a hybrid protein that activates A1CF. APOBEC3B deletion can be a major cause of changes in the endometriotic microenvironment, and contributes to the pathogenesis and manifestation of the disease. The effect of APOBEC3B deletion was proved by in-vitro experiments in a cell line model, which displayed endometriosis-like characteristics. APOBEC3B germline deletion plays a major role in the pathogenesis of endometriosis, which is evident by the activation of A1CF, an increase in epithelial to mesenchymal transition, cellular proliferation, inflammation markers and a decrease in apoptosis markers. CONCLUSION: The deleterious effects caused by APOBEC3B deletion in endometriosis were identified and confirmed. These results might provide a base for identifying the complete pathogenetic mechanism of endometriosis, thereby moving a step closer to better diagnosis and treatment options.

Endometrioma surgery: Hit with your best shot (But know when to stop).

Ovarian endometriomas (OEs) are commonly detected by ultrasound in individuals affected by endometriosis. Although surgery was widely regarded in the past as the gold standard for treating OEs, especially in the case of large cysts, the surgical management of OEs remains debated. Firstly, OEs often represent the "tip of the iceberg" of underlying deep endometriosis, and this should be considered when treating OEs to ameliorate patients' pain for focusing on the surgical objectives and providing better patient counseling. In the context of fertility care, OEs may have a detrimental effect on ovarian reserve through structural alterations, inflammatory responses, and oocyte reserve depletion. Conversely, the surgical approach may exacerbate the decline within the same ovarian reserve. While evidence suggests no improvement in in-vitro fertilization (IVF) outcomes following OE surgery, further studies are needed to understand the impact of OE surgery on spontaneous fertility. Therefore, optimal management of OEs is based on individual patient and fertility characteristics such as the woman's age, length of infertility, results of ovarian reserve tests, and surgical background. Among the available surgical approaches, cystectomy appears advantageous in terms of reduced recurrence rates, and traditionally, bipolar coagulation has been used to achieve hemostasis following this approach. Driven by concerns about the negative impact on ovarian reserve, alternative methods to obtain hemostasis include suturing the cyst bed, and novel methodologies such as CO2 laser and plasma energy have emerged as viable surgical options for OEs. In instances where sonographic OE features are non-reassuring, surgery should be contemplated to obtain tissue for histological diagnosis and rule out eventual ovarian malignancy.

Expression of Serum APRIL and NDRG1 Levels in Patients with Ovarian Endometrioma and Their Clinical Value / 现代检验医学杂志

Objective To observe the changes in serum a proliferation inducing ligand(a proliferation inducing ligand,APRIL)and N-myc downstream regulated gene 1(N-myc downstream regulated gene 1,NDRG1)levels,and analyze their diagnostic value for ovarian endometrioma(OEM).Methods From July 2021 to July 2022,132 patients with OEM who visited Zigong First People's Hospital were regarded as the observation group,and regular follow-up was conducted.According to the prognosis of these patients,they were grouped into the recurrence group(n=50)and the non recurrence group(n=82).Meanwhile,78 healthy individuals who had their medical checkups at the hospital during the same period were the control group.Enzyme linked immunosorbent assay(ELISA)was applied to detect serum APRIL and NDRG1 levels,and the general data of the recurrent and non recurrent groups were compared.Logistic regression analysis was applied to analyze the relevant factors affecting the prognosis of OEM.Pearson analysis was applied to explore the correlation between serum APRIL and NDRG1 levels in patients with OEM.Receiver operating characteristic(ROC)curve was applied to evaluate the diagnostic value of serum APRIL,NDRG1 levels and their combination for OEM.Results Compared with the control group,APRIL level(35.28±6.81ng/ml vs 26.37±3.19ng/ml)and NDRG1 level(124.39±15.67μg/L vs 9.67±10.82μg/L)in observation group were increased,and the differences were significant(t=10.864,17.278,all P<0.05).Compared with the non recurrence group,the serum levels of APRIL(40.38±7.88ng/ml vs 32.16±6.18ng/ml)and NDRG1(132.04±19.83μg/L vs 119.73±13.16μg/L)in the recurrence group were increased,and the differences were significant(t=6.668,4.287,all P<0.05).Logistic regression analysis showed that serum APRIL and NDRG1 levels were risk factors for the prognosis of patients with OEM(Waldχ2=11.839,28.437,all P＜0.001).Pearson method analysis results showed a positive correlation between serum APRIL level and NDRG1 level in patients with OEM(r=0.439,P<0.001).The area under the curve(AUC)of combined diagnosis of serum APRIL and NDRG1 levels in patients with OEM was 0.849,with a sensitivity and specificity of 73.95%and 85.37%,respectively,which was better than the single prediction of APRIL and NDRG1(Z =2.644,2.094,P=0.008,0.036).Conclusion The serum levels of APRIL and NDRG1 were increased in patients with OEM.The combination of the two has high clinical value in the diagnosis of OEM,which may be closely related to the prognosis of patients with OEM.

Assessment of Female Pelvic Pathologies: A Cross-Sectional Study Among Patients Undergoing Magnetic Resonance Imaging for Pelvic Assessment at the Maternity and Children Hospital, Qassim Region, Saudi Arabia.

Background and objectives Pelvic pathologies affect females in all age groups. They vary in size and location and can be wide in classification, such as masses, ectopic pregnancy, ovarian torsion, and ruptured ovarian follicles. Patients commonly present with gynecological complaints such as menstrual irregularities, abnormal pelvic bleeding, and infertility. Extra-gynecological symptoms such as dysuria and painful defecation can also manifest. To diagnose these pathologies, magnetic resonance imaging (MRI) and other imaging modalities can be useful alongside history and physical examination for early clinical diagnosis. Due to the importance of prevalence rate in predicting pathologies in a certain age and due to the lack of research studies on pelvic MRI studies in Qassim region, Saudi Arabia, this study aimed to demonstrate the wide spectrum of female pelvic pathologies that can be diagnosed using MRI in Qassim region, Saudi Arabia.  Methods and results A cross-sectional study was conducted among patients referred to the MRI Department for evaluation of female pelvic pathologies at the Department of Radiology at Maternity and Children Hospital in Buraydah, Qassim region, Saudi Arabia. A total of 325 patients were included in the study, with the majority being in the age group of 31-40 years. Fibroids were the most common pathology, being present in more than one-fifth of the study sample, followed by neoplastic growths and placental pathologies. Inflammatory pathologies were the least common pathologies, being present in approximately 5% of the participants. Statistically significant associations were found between the age groups, and the presence of anomalies (p = 0.009), existence of neoplastic changes (p < 0.001), presence of placental pathologies (p < 0.001), inflammatory changes (p = 0.025), and adenomyosis (p = 0.028). Conclusion MRI data offer important new information about the prevalence of various disorders among different age groups in the Qassim region of Saudi Arabia. Younger age groups had much higher rates of anomalies, whereas older age groups had much lower rates. Adenomyosis and neoplastic alterations were more prevalent in the later age groups, but endometrioma was more prevalent in younger age groups. Placental pathologies were more prevalent in women in their middle years, while scar pregnancy was more prevalent in women between 31 and 40 years of age. Younger people, especially those between 16 and 20 years of age, were more likely to experience inflammatory alterations. In the younger age group, there was no discernible association between age and the prevalence of normal outcomes. These findings help us understand how different illnesses manifest differently as we get older and emphasize the value of taking aging into account when diagnosing and treating disorders.

Effect of hormonal treatment on evolution of endometriomas: An observational study.

OBJECTIVE: To evaluate the evolution of endometriomas with or without medical treatment. METHODS: This retrospective observational study was performed at the Gynaecological Center, Hôpital La Conception (Assistance Publique Hopitaux de Marseille). We reviewed clinical data of patients with at least one endometrioma diagnosed by magnetic resonance imaging (MRI) and at least one other MRI exam after more than three months. Patients were divided into groups receiving medical treatment and without medical treatment (high-dose progestins, low-dose progestins or combined contraceptives). The primary objective was to evaluate the evolution of endometriomas with or without hormonal treatment. The primary evaluation criterion was the diameter of the endometriomas, and the secondary evaluation criterion was the number of endometriomas for each patient observed. The secondary objective was to evaluate whether different categories of hormonal treatment have different efficacity in the evolution of endometriomas. RESULTS: We included 68 patients, 39 (57,4%) with hormonal treatment and 29 (42,6%) without hormonal treatment. There were 105 total endometriomas identified at the first MRI, 52 in patients with hormonal treatment and 53 in patients without treatment. The mean diameter of the endometriomas in patients with hormonal treatment was 31,48 ± 18,1 mm at the first MRI and 23,60 ± 15,3 mm at the second MRI. The mean diameter of the endometriomas in patients without treatment was 33,57 ± 19,7 mm at the first MRI and 40,11 ± 25,7 mm at the second MRI (statistically significant difference, p = 0.01). The mean number of endometriomas in patients with treatment was 1,79 ± 1,1 at the first MRI and 1,18 ± 0,9 at the second MRI, while the mean number of endometriomas in patients without hormonal treatment was 1,38 ± 0,6 at the first MRI and 1,97 ± 1,5 at the second MRI (difference not statistically significant, p = 0.38). The subgroup analysis differentiated by category of hormonal treatment did not show statistically significant results. CONCLUSIONS: The present study shows that there is a positive effect of hormonal treatment on reducing the diameter of endometriomas and also a significative increase in endometrioma size in the absence of treatment. There is no evidence of an advantage of a single category of hormonal treatment on this effect on endometriomas. Thus, any medical treatment could be proposed as a first-line therapy for endometriomas that would reduce the size of the endometrioma and thereby help to avoid surgical intervention.

Diagnóstico ecográfico de la endometriosis y los miomas / Sonographic diagnosis of endometriosis and fibroids

La ecografía transvaginal se considera la prueba diagnóstica de elección en el estudio de la mujer con miomas, adenomiosis y endometriosis ovárica y profunda. Se recomienda realizar dicha ecografía siguiendo la sistemática exploratoria propuesta tras el consenso Morphological Uterus Sonographic Assessment (MUSA) para la patología miometrial, y el consenso IDEA para la endometriosis.Para realizar el diagnóstico de la adenomiosis, es necesario identificar como mínimo un criterio «directo» (islotes, yemas hiperecogénicas o quistes intramiometriales), así como uno o varios criterios indirectos (aspecto globuloso del útero, sombras «en abanico», asimetría de paredes miometriales o zona de transición endometrio-miometrio irregular). También definir si afecta a la capa externa uterina, o bien a la interna (zona de transición). La vascularización translesional de la adenomiosis es distinta a la circunferencial que presentan los miomas, de los que también debemos medir sus tres diámetros, describir su ecogenicidad y definir el número y la localización según la clasificación de la International Federation of Gynecology and Obstetrics (FIGO).La ecografía de la endometriosis se realiza mediante la exploración sistemática del útero y los ovarios (identificar y describir endometriomas), los marcadores menores o soft markers (pseudoquistes adherenciales perianexiales, líquido libre tabicado en Douglas, ovarios fijos, zonas sensibles a la presión y útero en forma de coma), el signo del deslizamiento (anterior, retrouterino y retrocervical) y la detección y descripción de los nódulos de endometriosis profunda en compartimento anterior (vejiga, uréteres) o posterior (ligamentos uterosacros, parametrios, fórnix vaginal, tabique rectovaginal y cara anterior de rectosigma).(AU)

Transvaginal ultrasound is considered the first-line imaging diagnostic test in the study of women with fibroids, adenomyosis, and ovarian and deep endometriosis. It is recommended that the ultrasound should follow the MUSA consensus for myometrial pathology, and the IDEA consensus for endometriosis.To diagnose adenomyosis, it is necessary to identify at least one «direct» criterion (hyperechogenic buds or island or intramyometrial cysts), as well as one or several «indirect» criteria (globulous uterine morphology, «fan-shaped» shadowing, asymmetry, or non-defined junctional zone). It is recommended to specify if the adenomyosis is internal or external. Translesional vascularization of adenomyosis is different from circumferential vascularization of fibroids, of which the measurement of the 3 diameters should be reported, the echogenicity should be described, and the number and location defined according to the FIGO classification.Ultrasound for endometriosis is performed by systematic examination of the uterus and ovaries (endometriomas), soft markers (periadnexal pseudocysts, tabicated fluid in the pouch of Douglas, fixed ovaries, tenderness-guide areas, and comma-shaped uterus), sliding sign (anterior, retrouterine, and retrocervical) and the detection and description of deep endometriotic nodules in the anterior (bladder, ureters) or posterior compartment (uterosacral ligaments, parametria, vaginal fornix, rectovaginal septum, and rectosigma).(AU)

Characteristics of patients with stage III and IV ovarian endometriomas and trends in postoperative anti-Mullerian hormone changes.

Introduction: This study aimed to investigate the manifestations of postoperative Anti-Mullerian hormone (AMH) changes in patients with stage III and IV ovarian endometriomas. Methods: Trends in postoperative AMH were categorized and described, and the risk factors for postoperative AMH decline were screened using dichotomous logistic regression. Results: The overall trend of postoperative AMH decreased, with a more significant decrease in stage IV than stage III cases. Elevated preoperative CA-125 levels, a history of caesarean section, and abortion were independent risk factors for postoperative AMH decline. Conclusions: There is a general trend toward decreasing AMH levels after surgery, but each case may also show a different elevation.

Gauze packing may be a better hemostatic method to protect ovarian reserve during laparoscopic endometrioma cystectomy than conventional hemostatic methods.

PURPOSE: To compare the ovarian reserve of different hemostatic methods after laparoscopic endometrioma stripping (LES) and explore which factors may affect ovarian reserve. METHODS: Patients who underwent LES from January 2019 to December 2021 were retrospectively included. Anti-Müllerian hormone (AMH) levels were measured before, and 3 months after surgery to determine changes of serum AMH in each patient. A multivariate linear regression analysis was performed to identify significant factors that were associated with the rate of decline of serum AMH levels at month 3 after surgery. RESULTS: A total of 67 patients who underwent LES were included. Of these patients, 20 with gauze packing, 24 with bipolar dessication (BD), and 23 with suture to achieve hemostasis. The 3 groups were similar in terms of demographics, cyst diameter, and basal AMH levels, except basal hemoglobin levels. At 3 months after surgery, the decline rate of AMH levels was significantly greater in the suture and BD group compared with the gauze packing group [48.2% (interquartile range, IQR, 28.1-67.1) and 31.1% (IQR,14.6-49.1) vs. 15.1% (IQR,1.1-24.5), P = 0.001]. On multivariate regression models, significant predictors of the decline rate of serum AMH levels at 3 months after surgery were hemostatic methods (p < 0.001), basal AMH levels (p = 0.033), and lesion bilaterality (p = 0.017). CONCLUSION: Compared to BD or suturing hemostasis, gauze packing hemostasis led to less damage on ovarian reserve at 3 months after LES. Besides, hemostatic methods, bilateral endometriomas and basal ovarian reserve were independently correlated with the impairment of ovarian reserve after surgery.

Expression of ZEB1 in different forms of endometriosis: A pilot study.

OBJECTIVES: Epithelial-Mesenchymal Transition (EMT), a cellular process in which epithelial cells lose epithelial characteristics while acquire mesenchymal features, is believed to contribute to migration and invasion abilities of the endometriotic cells. Studies on gene expression of the transcription factor ZEB1, a crucial transcription factor of EMT, show that there is probably a modified expression in the endometriotic lesions. The aim of the study was to compare the expression levels of ZEB1 in types of endometriotic lesions with different biological behavior such as endometriomas and deep infiltrating endometriotic nodules. STUDY DESIGN: We have studied 19 patients with endometriosis and 8 patients with benign gynecological lesions without endometriosis. The endometriosis patient group included 9 women with only endometriotic cysts without deep infiltrating endometriotic lesion (DIE) and 10 women with DIE who had developed concurrent endometriotic cysts. The technique applied to investigate ZEB1 expression levels is Real-Time PCR. The results of the reaction were normalized by simultaneously investigating the expression of the house-keeping gene G6PD. RESULTS: Analysis of the samples showed underexpression of ZEB1 in the eutopic endometrium of women with only endometriotic cysts when compared to normal endometrium. A tendency of higher ZEB1 expression, without reaching significant difference, was found between the endometriotic cysts and their paired eutopic endometrium. In women with DIE, no significant difference was found between their eutopic and normal endometrium. No significant difference was found between the endometriomas and DIE lesions. ZEB1 shows different expression profile in the endometriotic cysts of women with and without DIE when the cyst is compared to their paired eutopic endometrium. CONCLUSIONS: It therefore appears that ZEB1 expression differs between different types of endometriosis. The expression levels of ZEB1 in the eutopic endometrium could affect the development of infiltrating lesions or not. However, the most important observation is the different ZEB1 expression profile of endometriomas between women with and without DIE. Although, they both share the same histologic characteristics, they show different ZEB1 expression indicating different pathogenetic mechanisms of endometriomas in cases with and without DIE. Therefore, future research on endometriosis should consider DIE and ovarian endometriosis as different diseases.

Status and related factors of postoperative recurrence of ovarian endometriosis: a cross-sectional study of 874 cases.

PURPOSE: Exploring the status and related factors of postoperative recurrence of ovarian endometriosis. METHODS: This study analyzed the results of questionnaires conducted in 27 hospitals across the country from January 2019 to November 2021. All women were divided into recurrence group and non-recurrence group to analyze the recurrence rate and related factors after ovarian endometriosis surgery. RESULTS: The recurrence rates of ovarian endometriosis within 1 year, 1-2 years, 2-3 years, 3-4 years, 4-5 years and more than 5 years were 6.27%, 35.85%, 55.38%, 65.00% and 56.82%, respectively. Significant differences were found between two groups in terms of age at surgery (OR: 0.342, 95%CI: 0.244-0.481, P < 0.001), presence of dysmenorrhea (OR: 1.758, 95%CI: 1.337-2.312, P < 0.001), presence of adenomyosis (OR: 1.948, 95%CI: 1.417-2.678, P < 0.001) and family history of endometriosis or adenomyosis (OR: 1.678, 95%CI: 1.035-2.721, P = 0.021). The age at surgery (OR: 0.358, 95%CI: 0.253-0.506, P < 0.001), presence of dysmenorrhea (OR: 1.379, 95%CI: 1.026-1.853, P = 0.033) and presence of adenomyosis (OR: 1.799, 95%CI: 1.275-2.537, P = 0.001) were significantly associated with endometrioma recurrence in multivariate analysis. No significant associations were found between the recurrence rate and body mass index (BMI), educational background, age of menarche, gravida, parity, uterine leiomyoma, endometrial polyps or postoperative use of gonadotropin-releasing hormone agonist (GnRH-a). CONCLUSIONS: Dysmenorrhea and presence of adenomyosis are independent risk factors for postoperative recurrence of ovarian endometriosis, and older age is an independent protective factor for postoperative recurrence.

Effect of early inflammatory reaction on ovarian reserve after laparoscopic cystectomy for ovarian endometriomas.

This study aimed to investigate the effect of early inflammatory reaction on ovarian reserve of patients with ovarian endometriomas after laparoscopic cystectomy. Our retrospective case series included 112 patients with ovarian endometriomas that underwent the laparoendoscopic single-site cystectomy. Interleukin-6 (IL-6), hs-CRP, tumour necrosis factor-α (TNF-α), interleukin-17A (IL-17A) and AMH level were detected during perioperative and postoperative period. In our study, ovarian endometriomas with low AMH group were found having higher level of IL-6 than the normal AMH group in the preoperative status. On the 3rd day after operation, the change of AMH level was inversely proportional to the IL-6 level. During the follow-up within one year, it was found that the bilateral nature of the cyst and the postoperative IL-6 increased level were the risk factors for AMH not returning to baseline level. Our results suggested that inflammatory reaction is indeed involved in the damage of ovarian reserve during laparoscopic cystectomy. Hence, the negative impact of inflammatory injury should be fully considered before operation, especially young women with bilateral ovarian endometriomas.Impact StatementWhat is already known on this subject? Ovarian reserve in women always was reduced after the laparoscopic cystectomy. It is reported that it may be related to the use of energy instruments, haemostatic methods or the size of cysts in minimally invasive surgery.What do the results of this study add? Inflammatory reaction is indeed involved in the damage of ovarian reserve during LESS cystectomy. Interleukin-6 (IL-6) may act as the most main inflammatory factor aggravating damage of the ovarian reserve. Moreover, increased IL-6 level after surgery and bilateral cyst burden are the two risk factors for AMH not returning to baseline level within one year after surgery.What are the implications of these findings for clinical practice and/or further research? In clinic, the negative impact of inflammatory injury on ovarian reserve should be fully considered before operation, especially young women with bilateral ovarian endometriomas. Moreover, this is also the clinical basis for further study on the mechanism of inflammatory ovarian injury or the method of blocking the inflammatory response to reduce the damage of ovarian reserve after surgery.

A Practical Approach to Fertility Considerations in Endometriosis Surgery.

Endometriosis surgery requires thoughtful consideration and planning for those with infertility or those who wish to conceive in the future. Clinical history, examination, imaging, and fertility assessment can help plan, prepare and provide goal-directed surgical interventions when required. Further understanding of the benefits and limitations of surgery on future fertility outcomes is essential for those who provide care for patients with endometriosis. Endometriosis is a prevalent gynecologic condition, especially among patients with infertility. Studies demonstrate that, from a fertility perspective, surgery for endometriosis likely has a beneficial impact on the chance of spontaneous conception; however, selecting the appropriate surgical candidate can be challenging. To make a fully informed decision with regard to surgery, it is important to determine the patient's fertility goals and to conduct a thorough workup. Among patients with endometriosis-related infertility, first-line-assisted reproductive technology (ART) is generally preferred over surgery. Specific consideration in cases of minimal or mild endometriosis, ovarian endometrioma(s), and deep endometriosis (DE) are required for targeted counseling. Patients with symptoms significantly impacting their quality of life (QOL), or indications to proceed with surgery (ie, risk of malignancy, organ obstruction, or dysfunction) are best managed with surgical care by an experienced team. Surgery should be considered cautiously given the risks of damage to ovarian reserve, adhesions, and surgical complications. Risk of damage to ovarian reserve is a particularly important consideration among patients with endometrioma(s), with or without low ovarian reserve, and surgical complications are especially prevalent among patients undergoing surgery for bowel endometriosis. Goal-directed surgical treatment, as opposed to the traditional perspective of complete disease eradication, may be of particular importance among selected patients whereby fertility is a priority.

Identification of lesional attributes of dysmenorrhea severity and the serum antimüllerian hormone levels in women with ovarian endometriomas.

OBJECTIVE: To investigate whether lesional immunostaining of putative biomarkers of recurrence and the extent of lesional and cortical fibroses are correlated with the severity of dysmenorrhea and serum antimüllerian hormone (AMH) levels in women with ovarian endometriomas (OEs). DESIGN: Retrospective cohort study. SETTING: Academic hospital. PATIENT(S): A total of 313 women with histologically confirmed OEs were recruited. Their demographic and clinical information and data on their preoperative AMH levels were collected. Additionally, samples of their lesional tissues and ovarian cortex tissues adjacent to the OE lesions were procured for histologic and immunohistochemistry analyses. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): All OE tissue samples were stained for phosphorylated nuclear factor κB p65 subunit, progesterone receptor isoform B, Slit2, and α-smooth muscle actin. In addition, the extent of lesional and cortical fibroses was quantitated by Masson trichrome staining. We evaluated the relationship between the lesion size; laterality; extent of lesional and cortical fibroses, along with the putative markers of recurrence; and severity of dysmenorrhea and preoperative serum AMH levels in patients with OE. RESULT(S): We found that the extent of lesional fibrosis was positively correlated with the severity of dysmenorrhea but had no impact on the AMH levels. On the other hand, the extent of cortical fibrosis, along with age, was negatively correlated with the AMH levels. CONCLUSION(S): The correlation between lesional fibrosis and the severity of dysmenorrhea and between cortical fibrosis and the AMH levels would call an early intervention once OE is diagnosed or suspected to prevent further pain and diminished ovarian reserve.

Superinfected endometrioma, ultrasound guided drainage.

Infected endometriomas are rarely described in the literature with most cases being managed laparoscopically or open laparotomy. We present an infected endometrioma in a 48-year-old female with a history of extensive peritoneal adhesions in the setting of a contralateral tubo-ovarian abscess that was unresponsive to antibiotic therapy. Initially, the tubo-ovarian abscess was percutaneously drained, however, the patient did not clinically improve. The suspected infected endometrioma was then percutaneously drained which then led to clinical improvement. Typically, endometriomas are managed laparoscopically chiefly due to the risk of content spillage into the peritoneum, however, the case presented demonstrated that an ultrasound-guided transabdominal approach drainage can be feasible in a surgically complicated patient who was unresponsive to antibiotics in which a percutaneous approach was favored rather than a surgical approach.

Does current ovarian endometrioma increase the time for DOR patients to reach live birth in IVF?

BACKGROUND: The contents of ovarian endometrioma (OMA) such as inflammatory mediators, reactive oxygen species, and iron may disrupt normal folliculogenesis and result in subsequent oocyte apoptosis. Therefore, women with OMA have a potential risk of diminished ovarian reserve (DOR). The purpose of this study is to compare the in vitro fertilization (IVF) outcomes and efficiency between DOR patients with and without current OMA. METHODS: This retrospective case-control study included a total of 493 women with DOR (serum anti-Müllerian hormone level < 1.1 ng/mL). Ninety patients with OMA (Group A) underwent 191 IVF cycles and 403 patients without ovarian OMA (Group B) underwent 888 IVF cycles in our center between January 2014 and December 2018. Basal characteristics and IVF outcomes were compared between Group A and Group B. Time to achieve live birth were compared between patients with live birth in two groups (Group A1, 31 patients; Group B1, 132 patients). RESULTS: Clinical and demographic characteristics of patients were similar respectively between groups (A vs. B, A1 vs. B1). There were no statistically significant differences in implantation rate, live birth rate per OPU and per ET cycle and the cumulative live birth rate per patient and per patient with good-quality embryos between Group A and Group B (P > 0.05). Total time to achieve live birth has no statistically significant difference between Group A1 and Group B1 (P > 0.05). CONCLUSION: For DOR women, presence of endometrioma did not affect the IVF outcomes. Even the time to get live birth was not prolonged by current OMA.

Impact of perioperative use of GnRH agonist or dienogest on ovarian reserve after cystectomy for endometriomas: a randomized controlled trial.

BACKGROUND: Ovarian endometrioma is a common gynecological disease that is often treated with surgery or hormonal treatment. Ovarian cystectomy, a surgical procedure for ovarian endometrioma, can result in impaired ovarian reserve. METHODS: We conducted a randomized controlled trial to evaluate the efficacy of hormonal treatment [gonadotropin-releasing hormone agonist (GnRHa) or dienogest (DNG)] for preserving ovarian reserve after cystectomy for ovarian endometrioma. The primary endpoint was the level of serum Anti-Müllerian hormone (AMH) as a marker of ovarian reserve. RESULTS: Before and after laparoscopic surgery, 22 patients in the GnRHa group and 27 patients in the DNG group were administered hormonal treatment for a total of 4 months. After 1-year follow-up, >60% of the patients in the DNG group retained over 70% of their pretreatment AMH levels, whereas no patient in the GnRHa group retained their AMH levels after cystectomy (P < 0.01). Interleukin-6 (IL-6) is a key cytokine involved in inflammation. Compared with the GnRHa group, patients in the DNG group had lower IL-6 levels at the end of treatment. CONCLUSIONS: Our data revealed that DNG is more effective than GnRHa in preserving ovarian reserve after cystectomy of ovarian endometrioma. This is achieved through the reduction of the inflammatory response during the perioperative period and other endometriosis-related inflammatory reactions. TRIAL REGISTRATION: The registration number of this trial is UMIN-CTR, UMIN000018569, registered 6 August 2015, https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000021492 , and Japan Registry of Clinical Trials, jRCTs041180140, registered 29 March 2019, https://jrct.niph.go.jp/en-latest-detail/jRCTs041180140 . This randomized controlled trial was conducted in accordance with the CONSORT guidelines.

Oocyte accumulation for fertility preservation in women with benign ovarian tumours with a history of previous surgery, multiple or large cysts.

RESEARCH QUESTION: What are ovarian stimulation cycle outcomes and acceptance rates of an oocyte accumulation programme in young women with benign ovarian tumour (BOT)? DESIGN: Retrospective cohort study conducted at the Academic Assisted Reproductive Technology and Fertility Preservation Centre, Lille University Hospital, between January 2016 and December 2019. The number of metaphase II oocytes per cycle and per patient after accumulation were evaluated. Two groups were identified for the analysis: endometrioma ('endometrioma') and dermoid, mucinous or serous cyst ('other cysts'). RESULTS: A total of 113 fertility-preservation cycles were analysed in 70 women aged 27.9 ± 4.8 years. Almost all women had undergone previous ovarian surgery before fertility preservation (89%). Mean anti-Müllerian hormone levels before ovarian stimulation was 12.5 ± 8.7 pmol/l. A total of 6.4 ± 3.4 oocytes were retrieved, and 4.3 ± 3.4 metaphase II (MII) oocytes were vitrified per cycle. All agreed to the oocyte accumulation programme and all underwent at least one cycle. To date, 36 (51%) patients achieved two or three fertility- preservation cycles. After accumulation, 7.0 ± 5.23 MII oocytes were vitrified per patient. No difference was found in ovarian response and oocyte cohort between the 'endometrioma' and 'other cysts' groups. Questionnaires completed after oocyte retrieval revealed abdominal bloating and pelvic pain in most patients, with no difference according to the type of cyst. No serious adverse events occurred. CONCLUSIONS: Oocyte accumulation should be systematically offered to young women with BOT irrespective of histological type, as it seems to be well-tolerated. Long-term follow-up is needed to assess the efficiency of oocyte accumulation to optimize the chances of subsequent pregnancies.

Anastrozole and levonorgrestrel-releasing intrauterine device in the treatment of endometriosis: a randomized clinical trial.

BACKGROUND: To study the effectiveness of an aromatase inhibitor (Anastrozole) associated with levonorgestrel-releasing intrauterine device (LNG-IUD, Mirena®) in the treatment of endometriosis. METHODS: Prospective, randomized clinical trial. SETTING: University Hospital (single center). Elegibility criteria: Endometriomas > 3 × 4 cm, CA-125 > 35 U/mL and endometriosis symptoms. PATIENTS: Thirty-one women randomized to anastrozole + Mirena® + Conservative Surgery(CS) (n = 8), anastrozole + Mirena® + transvaginal ultrasound-guided puncture-aspiration (TUGPA) (n = 7), Mirena® + CS (n = 9), or Mirena® + TUGPA (n = 7). INTERVENTIONS: Anastrozole 1 mg/day and/or only Mirena® for 6 months; CS (ovarian and fertility-sparing) or TUGPA of endometriomas one month after starting medical treatment. MAIN OUTCOME MEASURES: Visual analogic scale for symptoms, CA-125 levels, ultrasound findings of endometriomas and recurrences. RESULTS: A significant improvement in symptoms during the treatment (difference of 43%, 95% CI 29.9-56.2) occurred, which was maintained at 1 and 2 years. It was more significant in patients including anastrozole in their treatment (51%, 95% CI 33.3-68.7). For CA-125, the most significant decrease was observed in patients not taking anastrozole (73.8%, 95% CI 64.2-83.4 vs. 53.8%, 95% CI 25.7-81.6 under Mirena® + anastrozole). After CS for endometriosis, a reduction of ultrasound findings of endometriomas and long-term recurrence occurred, with or without anastrozole. At 4.2 ± 1.7 years (95% CI 3.57-4.85), 88% of the patients who underwent CS were asymptomatic, without medication or reoperation, compared to only 21% if TUGPA was performed, with or without anastrozole (p = 0.019). CONCLUSIONS: Dosing anastrozole for 6 months, starting one month before CS of endometriosis, reduces significantly the painful symptoms and delays recurrence, but has no other significant advantages over the single insertion of LNG-IUD (Mirena®) during the same time. Anastrozole and/or only Mirena® associated with TUGPA are not effective. TRIAL REGISTRATION: Eudra CT System of the European Medicines Agency (London, 29-Sept-2008) Nº EudraCT: 2008-005744-17 (07/11/2008). Date of enrolment of first patient: 15/01/2009.