JBRA Assist. Reprod 2007;11(3):36-38
ARTIGO DE REVISÃO
doi: 10.5935/1518-0557.2007.11.3.07
Departments of Obstetrics and Gynecology and Reproductive Medicine ( J.B.S., C.F., R.F., R.F.), Clamart, France
ABSTRACT
Endometriosis is a common gynaecological disorder in which endometrial tissue (glandular epithelium and stroma) is found outside the uterine cavity. It affects 20-40% of women who complain of subfertility, although it can be found also in 5-10% of fertile women. Endometriosis mostly presents as superficial and deep pelvic peritoneal implants, adhesions and ovarian cysts. Characteristic symptoms include dyspareunia, severe dysmenorrhoea and chronic pelvic pain. It has been believed for almost a century by the majority of academic opinion that endometriosis is a disease caused by shedding of menstrual endometrium and its dissemination throughout the pelvis. Transvaginal ultrasound is an increasingly accepted technique for the diagnosis of an ovarian endometrioma. The primary indications for treatment of ovarian endometriomas are the symptoms of pelvic pain and dyspareunia (pain during or after sexual intercourse). There is a lack of randomized controlled studies to report definitively the impact of endometriomas and conservative surgery of ovarian prior to IVF/ICSI cycles. The most effective method of laparoscopic surgery remains controversial.
Key words: Endometriosis /ultrasonics /surgery
RESUMO
Endometriose é uma desordem ginecológica comum em que o tecido endometrial (epitélio e estroma glandular) é encontrado fora da cavidade uterina. Afeta 20-40% das mulheres subférteis, embora se possa encontrar também em 5-10% de mulheres férteis. Endometriose apresenta-se na maior parte como implantes pélvicos superficiais e profundos, adesões e cistos ovarianos. Os sintomas característicos incluem a dispareunia, a dismenorréia severa e a dor pélvica crônica. Foi acreditado por quase um século pela maioria da opinião acadêmico que a endometriose é uma doença causada pelo escoamento do endométrio menstrual e sua disseminação pela pelve. O ultrasom transvaginal é uma técnica cada vez mais aceita para o diagnóstico de um endometrioma ovariano. As indicações preliminares para o tratamento de endometriomas ovarianos são os sintomas da dor pélvica e da dispareunia (dor durante ou após o intercurso sexual). Há uma falta de estudos controlados randomizados para relatar definitivamente o impacto dos endometriomas e a cirurgia conservadora antes dos ciclos de fertilização in vitro e injeção intracitoplasmática de espermatozóides (IVF/ICSI). O método mais eficaz da cirurgia laparoscópica permanece controverso.
Palavras chave: Endometriose /ultra-som /cirurgia
CONTEXT
Endometriosis is a common gynaecological disorder in which endometrial tissue (glandular epithelium and stroma) is found outside the uterine cavity. It affects 20-40% of women who complain of subfertility, although it can be found also in 5-10% of fertile women. Endometriosis mostly presents as superficial and deep pelvic peritoneal implants, adhesions and ovarian cysts. Characteristic symptoms include dyspareunia, severe dysmenorrhoea and chronic pelvic pain (Hart et al., 2005).
It has been believed for almost a century by the majority of academic opinion that endometriosis is a disease caused by shedding of menstrual endometrium and its dissemination throughout the pelvis (Cullen, 1920; Sampson, 1927). The origin of ovarian endometriomas, endometriotic deposits within the ovary, is unknown; however, most authors believe that they result initially from a deposit of endometrium passed through the Fallopian tube, causing adherence of the ovary to the pelvic peritoneum and progressive invagination (folding inwards) of the ovary (Hughesdon, 1957; Brosens et al., 1994; Nisolle & Donnez, 1997). If this is true, an endometrioma would be a pseudocyst (false cyst), the wall of which is the inverted ovarian cortex (centre) and hence the removal of this cyst wall might involve removal of normal ovarian tissue, with possible adverse implications for future fertility (Yazbeck et al., 2006).
Transvaginal ultrasound is an increasingly accepted technique for the diagnosis of an ovarian endometrioma. In a recent review, Moore et al. (2002) identified 38 articles related to the diagnosis of endometriosis by ultrasound scan, but only seven studies were found to be sufficiently sound for further analysis. The authors concluded that transvaginal ultrasound is indeed a useful test to detect or to exclude the presence of an ovarian endometrioma. However, the size of the endometriomas included in these studies ranged from 20 mm to 200 mm, with a mean of 40 mm, which suggests that the resolution obtained with current ultrasound techniques is inadequate to detect smaller endometriomas (Brosens, 2004).
The primary indications for treatment of ovarian endometriomas are the symptoms of pelvic pain and dyspareunia (pain during or after sexual intercourse). The evidence suggests that, although medical treatment will result in a reduction in size of the endometrioma of up to 57%, the most effective approach to treatment is surgical (Farquhar & Sutton, 1998), but it may impair the outcome of fertility treatment (Yanushpolsky et al., 1998).
Several alternative laparoscopic techniques have been described for the treatment of ovarian endometriomas: cyst wall laser vaporization (destruction by burning) preceded or not by medical therapy (Brosens et al., 1996), drainage and coagulation, and stripping (Canis et al., 1992). The procedure of drainage of the endometrioma alone is not recommended due to the risk of infection and a high rate of recurrence (Vercellini et al., 1992; Donnez et al., 2002; Audebert, 2005). However, the most effective method of laparoscopic surgery (excisional or ablative) remains controversial. Following ovarian endometrioma cystectomy, some studies have shown conflicting results on ovarian response, with some patients showing a detrimental effect (Tinkanen & Kujansuu, 2000; Ho et al., 2002) and others showing no adverse effect (Canis et al., 2001; Marconi et al., 2002).
There is a lack of randomized controlled studies to report definitively the impact of endometriomas and conservative surgery of ovarian prior to in vitro fecundation (IVF/ICSI) cycles (Garcia-Velasco et al., 2004). The causes of the reduced ovarian reserve in operated ovaries have been poorly investigated. In this regard, it is important to note that, at present, there are no definitive data to clarify whether the damage is related to the surgical procedure and/or to the previous presence of the cyst. Indeed, it cannot be excluded that the cyst per se may damage the surrounding ovarian tissue. Using pathological sections of the ovarian cortex surrounding ovarian endometriomas, Maneschi et al. (1993) found a reduced number of follicles antecedent to surgery, suggesting that the disease per se may be detrimental to the ovary. A major concern is that resection of endometriomas results in the loss of small follicles adjacent to the cyst wall and a reduced oocyte pool, which itself is associated with infertility (Exacoustos et al., 2004). In fact, several retrospective studies have reported reduced responses to gonadotrophins after cystectomy for ovarian endometriomas in young women (Somigliana et al., 2006) and ovarian endometrioma cystectomy before starting ovulation induction in assisted reproduction cycles does not seem to improve the cycle outcome in asymptomatic and uncomplicated patients with certain diameters (Garcia-Velasco et al., 2004). However, failure to operatively address the endometrioma might result in continued discomfort and potential complications, such as cyst rupture (endometrioma>4cm) (Wong, 2004) and the possibility of malignancy (Nishida et al., 2000).
In conclusion, it would seem that the age of the patient, the certainty of diagnosis, and the patient’s symptoms are important factors to consider when counseling whether to consider conservative ovarian surgery or proceed directly to controlled ovarian hyperstimulation (COH). Proceeding directly to COH in asymptomatic women with ovarian endometriomas might reduce the time to pregnancy, diminish patient costs, and avoid the potential complications of surgery. Conversely, asymptomatic women with ovarian endometriomas > 4 cm and symptomatic women with ovarian endometriomas might be advised to surgical treatment.
Brosens I. A. - Is mild endometriosis a progressive disease? Hum. Reprod., 9: 2209-2211, 1994.