Pelvic floor physiotherapy for endometriosis

Pelvic floor physiotherapy for endometriosis

A prospective study in the journal Ultrasound in Obstetrics & Gynecology has found that women treated with pelvic floor physiotherapy showed a significant improvement in pelvic floor relaxation, superficial dyspareunia and chronic pelvic pain, in comparison to women who did not receive treatment.

Simona Del Forno, MD, PhD, a consultant in ob/gyn in the Gynecology and Human Reproduction Physiopathology Unit of St. Orsola University Hospital in Bologna, Italy, was the principal investigator.

She said that she expected to find an improvement in superficial dyspareunia, defined as pain during sexual intercourse occurring in or around the vaginal entrance, because they had previously studied and demonstrated the association of this symptom with pelvic floor muscle hypertonia.

What surprised me, though, was the improvement in chronic pelvic pain, because of the complex physiopathology of the symptom and the difficulties in treating,” she said.

The inspiration for the study came from Del Forno’s clinical practice, where she noticed that many women with endometriosis suffered from pain during sexual intercourse, which was often not completely relieved by traditional therapies, either medical or surgical, and was frequently associated to pelvic floor muscle hypertonia.

The primary aim of the study was to evaluate the effects of pelvic floor physiotherapy on changes in the area of the levator ani muscle hiatus under the Valsalva maneuver via 3D/4D transperineal ultrasound in women with deep infiltrating endometriosis suffering from superficial dyspareunia.

The randomized controlled trial equally divided 34 nulliparous women diagnosed with deep infiltrating endometriosis and associated superficial dyspareunia to 1 of 2 groups: 5 individual sessions of pelvic floor physiotherapy of 30 minutes each at weeks 1, 3, 5, 8 and 11 (study group, n = 17) and no intervention (control group, n = 17).

Baseline and 4-month follow-up measurements of pain symptoms and transperineal ultrasound were compared. During both ultrasound examinations, the levator hiatal area was measured at rest, upon maximum pelvic floor muscle contraction and maximum Valsalva maneuver.

Of the 30 women who completed the study and were included in the analysis (study group, n = 17; control group: n = 13), the percentage change in levator hiatal area at maximum Valsalva maneuver was higher in the study group than in the control group: 20.0 vs. -0.5 (P = 0.02).

The change in the Numerical Rating Scale (NRS) score of superficial dyspareunia was also higher in the study group than in the control group: median interquartile range -3 (-4, -2) vs. 0 (0, 0), respectively (P < 0.01).

In addition, the second examination revealed significant differences between the two groups in chronic pelvic pain changes: median interquartile range 0 (-2,0) in the study group vs. 0 (0,1) in the control group (P = 0.01).

I believe that in women with endometriosis suffering from chronic pelvic pain, the use of multiple therapeutic strategies, including pelvic floor physiotherapy, may be the key to success,” Del Forno told Contemporary OB/GYN.

Pelvic floor physiotherapy may represent an additional valid, minimally invasive, innovative, and well-tolerated therapeutic option for women with endometriosis, in the modern perspective of a tailored and multidisciplinary therapeutic strategy.”

The study group scheduled individual sessions of physiotherapy with the same physiotherapist and the same clinical group. “We dedicated time, without any rush, in a quiet space to make all women feel comfortable,” Del Forno said. “I believe this environment may have contributed to the success of the study and to the high levels of women’s satisfaction and compliance with the physiotherapy.”

3D/4D transperineal ultrasound might also be a viable noninvasive method to assess pelvic floor muscles in these women, according to Del Forno.

The study authors plan to confirm results in a larger group of women and to assess long-term the maintenance of outcomes. “We also aim to extend the clinical use of pelvic floor physiotherapy in women with other gynecological diseases suffering from dyspareunia,” Del Forno said.

Read more: https://obgyn.onlinelibrary.wiley.com/doi/abs/10.1002/uog.23590

Endometriosis impacts life on many levels

Endometriosis impacts life on many levels

Research indicates that women with endometriosis are prone to physical, psychosocial, social, and sexual disturbances and obstetrical complications, according to a literature search of the impact of endometriosis on various aspects of reproductive health in the Journal of Obstetrics and Gynaecology.

Although endometriosis is not a life-threatening disease, the analysis concluded that it can significantly affect a patient’s reproductive health. “Endometriosis can be both physically and emotionally debilitating,” wrote the authors from Iran.

The authors searched four international databases for studies published in English on health issues in women with endometriosis from January 1995 to December 2019: PubMed, Science Direct, Scopus and Google scholar. A total of 46 full-text articles comprised the analysis.

Most of the papers were published in 2010 or later, reflecting a recent increase in research on the impact of endometriosis on reproductive health.

The majority of papers were also from high-income countries with developed healthcare systems: United Kingdom (n = 9), the United States (7), Brazil (5), Australia (3) Italy (3), Switzerland (2) and Japan.

The 40 quantitative studies consisted of 16 reviews, 12 cohort studies, 9 cross-sectional studies and 3 clinical trials. Conversely, the 6 qualitative studies used a range of quality-of-life instruments and assessments of variables such as symptoms, including pain; well-being; mental health; personality; and impact on work. The qualitative studies also relied on interviewing for data collection.

Study sample size varied considerably: from 16 to 116,430 women with endometriosis in quantitative studies and from 18 to 65 women with endometriosis in qualitative studies.

In addition, most of the participants had confirmed endometriosis through surgical diagnoses, for example; however, for others, diagnosis was self-reported and not clinically verified.

The physical impact from endometriosis pain can lead to complications, including chronic pelvic pain, dysmenorrhoea, dyspareunia, dyschezia and dysuria, which can decrease quality of life.

Likewise, the psychological health of women can be negatively impacted by infertility caused by endometriosis.

The social impact from endometriosis also can be exacerbated by absence from work, fewer social activities, and students missing school due to menstrual symptoms.

The disease, especially when linked to severe dyspareunia or chronic pelvic pain, can have negative effects on women’s sexual function as well, including sexual desire, orgasm, sexual satisfaction and frequency of intercourse. Fear of separation from partner can also lead to unwanted sex.

Many women with endometriosis suffer pain during sex and even have dyspareunia after intercourse.

Endometriosis also can significantly impair pregnancy by increasing the risk of miscarriage gestational diabetes, and hypertensive disorders.

The authors said it is crucial that women be informed about endometriosis and that information be easily accessible in order to improve their reproductive health. They also noted that sexuality is an integral part of one’s personality, which is adversely affected by endometriosis.

Because gynecologists are the first referral for suffering women, it is of utmost importance that they engage in a “profound conversation” with patients about their sexuality, despite the fact that sexuality is often perceived as a “shameful topic.”

Similarly, patients should engage their partners in decision-making, communicating and understanding the nature of endometriosis and its potential impact on the partner and family.

However, more research is needed to elucidate endometriosis complications, according to the authors, specifically for obstetrical outcomes.

Read more: https://www.tandfonline.com/doi/abs/10.1080/01443615.2020.1862772

Dienogest for endometriosis

Dienogest for endometriosis

A study in the Journal of Obstetrics and Gynaecology found that dienogest was effective in decreasing the size of endometrioma and reducing endometriosis-associated pain, along with a favorable safety and tolerability profile.

The prospective study from Turkey recruited 30 patients diagnosed with endometrioma at Erciyes University Medical Faculty Hospital in Kayseri, Turkey, between November 2015 and September 2016.

Only 24 patients were included in the study because three patients were unable to complete the dienogest therapy due to menstrual irregularities, two patients did not attend to regular controls, and one patient was operated on at another hospital.

The mean age of the 24 patients was 29.58 years, with a mean body mass index (BMI) of 25.9. The endometriomas in 86.67% of the patients were unilateral.

Patients were instructed to take a single daily 2 mg dose of the synthetic oral progestogen continuously through the 6-month study period, preferably at the same time each day.

Patients were examined for efficacy and side effects at baseline, 3 months and 6 months.

The mean volume of the endometrioma decreased a significant 41% from 112.63 ± 161.31 cm³ at baseline to 65.47 ± 95.69 cm³ at 6-month follow-up (P = 0.005).

A visual analog scale (VAS) from 0 to 10 (0: no pain, 10: unbearable pain) for pelvic pain also decreased significantly from 7.50 to 3.00 at 6 months after treatment (P < .001).

The most common side effect was abnormal vaginal bleeding, consisting of prolonged and frequent uterine bleeding or spotting (16.6%), followed by weight gain (8.3%), headache (8.3%), depressed mood (8.3%), dizziness (4.1%) and libido reduction (4.1%).

Laparoscopic excisional surgery for endometrioma is currently the most valid approach in the treatment of endometriomas,” wrote the authors. “However, there are concerns about ovarian reserve damage during surgery.”

Because there is no consensus on the timing of surgery in young women and whether surgery should be delayed in infertile women planning in vitro fertilization (IVF), strategies to eliminate or decrease the size of ovarian endometriomas without affecting a young woman’s fertility potential need to be designed, according to the authors.

One potential solution is presurgical administration of a gonadotropin-releasing hormone agonist (GnRH agonist), which renders conservative laparoscopic surgery easier for endometriosis and might reduce postsurgical damage to ovarian function by reducing active inflammation, adhesion of endometriotic lesions and the size of the endometrial cysts.

However, GnRH agonist therapy causes adverse effects by the deficiency of the ovarian hormone, such as an irregular menstrual period, hot flashes, vaginal burning, decreased sexual interest, and bone mineral density loss.

On the other hand, dienogest for IVF patients with an endometrial cyst prior to oocyte pick-up might facilitate oocyte pick-up and prevent bacterial infection post-procedure.

Long-term use of dienogest in younger patients with endometriomas who are yet to give birth may reduce the possibility of surgery by reducing the size of the endometriomas and may preserve ovarian reserve,” wrote the authors.

In addition, dienogest could reduce the incidence of infectious complications from pelvic abscess after oocyte retrieval and from surgical procedures for infertile patients with endometrioma.

The authors said clinicians should consider dienogest prior to initiation of an IVF cycle to reduce endometrioma size.

Read more: https://pubmed.ncbi.nlm.nih.gov/33629621/

Improving fertility rates and symptoms for peritoneal endometriosis

Improving fertility rates and symptoms for peritoneal endometriosis

For patients suffering from symptomatic early-stage endometriosis, a consistent excision of altered peritoneum followed by adjuvant hormonal therapy and multimodal concepts improves outcomes, particularly for pregnancy and recurrence rates.

This is the major finding of a German prospective study in the Archives of Gynecology and Obstetrics.

Clinically managing endometriosis is a huge challenge,” said principal investigator Sylvia Mechsner, MD, head of the Endometriosis Centre Charité at Charité University Hospital in Berlin. “We need to find a good balance between conservative and surgical treatment.”

Mechsner has had success by starting with sufficient hormonal treatment like therapeutic amenorrhea, especially when no organ damage is suspected. “Many patients achieve good pain relief,” she said. “But when is surgery a better option?”

Ongoing pelvic pain while taking sufficient hormonal treatment is Mechsner’s No. 1 consideration for surgery. “I believe neurogenic inflammation is present in most lesion cases and can cause non-estrogen related pain,” she said. “This is acyclical pain, due to changes in the sensory and sympathetic nerve fiber composition/innervation.”

For the study, patients stopped hormonal treatment 2 months prior to surgery, consisting of a resection not only of the visible lesions, but of the inflamed altered surrounding tissue as well.

Of course, infertility or seeking pregnancy are also indications for the surgery,” Mechsner told Contemporary OB/GYN. “We wanted to prove this concept and analyze the extension of inflammation in the excised tissue and the pain relief and fertility rate.”

The prospectively maintained database at the Endometriosis Centre Charité identified all symptomatic women with the suspicion of only peritoneal endometriosis who underwent laparoscopy from January 2014 to June 2019.

Laparoscopic peritonectomy was performed on 94 women, all by Mechsner. Follow-up data were available for 87% of the cases.

At the time of surgery, nearly all patients showed signs of stage I or II endometriosis: 44.7% and 48.9%, respectively.

Roughly 75% of the women reported pain relief due to the post-surgical hormonal therapy, with 25% completely pain free.

It was unexpected, but made me happy, to see so many women achieve some pain relief,” Mechsner said. “However, in many of these cases, we found severe adenomyosis. And in cases of organ-sparing surgery, it is logical that uterus-associated pain could be persistent.

Some patients also suffer from severe chronic pelvic pain syndrome with central sensitization, thus needing ongoing multimodal treatment like hormonal treatment, osteopathy, manual therapy, pelvic floor relaxing exercises, transcutaneous electrical nerve stimulation (TENS), pain management and psychological support.

The study found that 33% of women wanted to have children after the procedure, of whom 63% became pregnant, with the majority not requiring assisted reproductive therapy (ART).

Seven of the women had a reoperation.

According to the findings, “a consistent excision of altered peritoneum followed by adjuvant hormonal therapy and multimodal concepts results in better outcomes for the patient, particularly in regards to pregnancy and recurrence rates”.

Two limitations of the study are no control group and limited to a single center.

I believe it is good to know that endometriosis-related pain should be treated conservatively, especially in cases when no organ damage is suspected,” Mechsner said. “It is also reassuring to know that there is no need to schedule surgery for diagnosis only because the study’s protocol confirmed the peritoneal lesions in 100% of women.”

But in cases of ongoing acyclical pelvic pain, “it appears that peritoneal lesions are the cause of the pain, for which surgery with destruction/excision is recommended,” she said.

Read more: https://pubmed.ncbi.nlm.nih.gov/33537880

Scientists discover possible genetic target for treating endometriosis

Scientists discover possible genetic target for treating endometriosis

Michigan State University researchers have identified a potential genetic target for treating an especially painful and invasive form of endometriosis.

Their study published in Cell Reports, a scientific journal, could lead to better treatments for women suffering from severe forms of endometriosis, said Mike Wilson, a postdoctoral fellow in the MSU College of Human Medicine. Wilson and Jake Reske, a graduate student in the MSU Genetics and Genome Sciences Program, are first authors of the study.

Their research focused on a type of endometriosis that occurs in women who have a mutation in a gene called ARID1A, which is linked to the more invasive and painful form of the disease.

When ARID1A is mutated, so-called “super-enhancers,” a part of the DNA that determines the function of cells, run wild, Reske said. This allows the cells that normally line the uterus to form deep implants outside the uterus and cause severe pelvic pain.

“There haven’t been many successful nonhormonal therapies for this form of endometriosis that have made it to the bedside yet,” Reske said.

In laboratory experiments, he and Wilson tested a drug that appeared to target the super-enhancers and stop the spread of endometriosis. Such a drug — part of a new type of treatment called “epigenetic therapy” that controls how genes are expressed — could be far more effective than current treatments, including surgery, hormone therapy and pain management.

Endometriosis, particularly the kind associated with the ARID1A mutation, can be debilitating for many women, often leading to infertility.

“It can seriously impact women’s quality of life and their ability to have a family and work,” said Ronald Chandler, an assistant professor of obstetrics, gynecology and reproductive biology, who supervised the study. “It’s not easy to treat, and it can become resistant to hormone therapy. The most clinically impactful thing we found is that targeting super-enhancers might be a new treatment for this deeply invasive form of the disease.”

The drug they studied targeted a protein in cells called P300, suppressing the super-enhancers and offsetting the effects of the ARID1A mutation, Wilson said. The same type of treatment could be used to treat other forms of endometriosis, he said.

The researchers already are planning follow-up studies to find other drugs that could target P300, Wilson and Reske said.

The MSU team collaborated with Van Andel Institute researchers, providing them with tissue samples for VAI scientists to analyze with a machine called a next-generation sequencer.

Read more: https://linkinghub.elsevier.com/retrieve/pii/S2211124720313553

Impact of opioids in women with endometriosis

Impact of opioids in women with endometriosis

The risk of opioid use after endometriosis diagnosis is significantly greater in patients who used opioids before diagnosis, according to a retrospective analysis of data from a large health database.

The analysis in the Journal of Comparative Effectiveness Research also found that the risk of prolonged opioid use was significantly greater if comorbidities existed before diagnosis.

Senior author Georgine Lamvu, MN, MPH, a professor of ob/gyn at the University of Central Florida College of Medicine in Orlando, was prompted to undertake the analysis after a colleague remarked to her that he did not believe that women with endometriosis used opioids.

In my practice, I had seen many women with endometriosis who reported using opioids, so I was curious to find out the actual numbers,” Lamvu told Contemporary OB/GYN.

Medical and pharmacy claims information on 79,947 women with endometriosis from July 2015 to June 2018 were analyzed from the Symphony Health database.

The date of the first endometriosis diagnosis was deemed the index date and the 1-year period preceding the index data was considered the baseline period.

Women were aged 18 to 49 at the index date and had continuous pharmacy and medical enrollment for at least 1 year before and after their endometriosis diagnosis; in other words, at least one pharmacy claim every 3 months during the study period.

Women with endometriosis who used opioids at baseline were 61% more likely to receive opioids post-diagnosis.

The risk of prolonged opioid supply post-diagnosis was highest among women with a prolonged supply at baseline: relative risk (RR) 21.14, which significantly decreased to 1.32 for patients without a prolonged supply but with at least one comorbidity, 1.37 for pain comorbidities and 1.07 for psychiatric co-morbidities.

I was surprised to find out how many women with endometriosis actually used opioids beyond 90 days,” Lamvu said. “All the other findings were expected.”

There is limited evidence to indicate that long-term opioid therapy is effective in treating other chronic pain conditions and no research to validate that opioids are efficacious for endometriosis-related pain.

Nonetheless, the risk of opioid-related adverse events correlates with the dose and duration of opioid use,” Lamvu said. “This can lead to opioid-induced hyperalgesia, which counterproductively amplifies pain.”

In addition, high daily doses and prolonged use of opioids for chronic non-cancer pain can increase the risk of opioid abuse. More definitive is that comorbid psychiatric disorders in patients with chronic pain conditions like low back pain are linked to opioid misuse.

The high prevalence of psychiatric comorbidities in patients with endometriosis suggests that this population may be vulnerable to opioid misuse,” Lamvu said.

Optimal endometriosis treatment should encompass a patient-centric strategy, according to Lamvu, integrating pharmacologic and surgical options to manage symptoms, in conjunction with therapies to improve health-related quality of life.

Multi-disciplinary care with adequate management of comorbidities could optimize endometriosis treatment and reduce inappropriate or excessive treatment with opioids,” Lamvu said.

The analysis identifies a group of women who need specific counseling on the risks of long-term opioid use. “However, because we have no research that shows that opioids are effective for endometriosis-related pain, we need more research on this topic,” Lamvu said. “Also, because many women with endometriosis have surgery, post-op opioid use needs to be discussed with caution.”


Postoperative outcomes after surgery for deep endometriosis of sacral plexus

Postoperative outcomes after surgery for deep endometriosis of sacral plexus

Laparoscopic management of deep endometriosis involving the sacral roots and the sciatic nerve improves patient symptoms and overall quality of life, according to a retrospective case series.

The study in the Journal of Minimally Invasive Gynecology also concluded that although pain reduction may be rapid following surgery, other sensory or motor complaints might persist for months to years.

The study assessed 1-year postoperative outcomes in patients managed for big endometriosis nodules involving the sacral plexus, which control bowel and bladder function, motility and sensitivity of perineum, buttock and inferior leg,” said principal investigator Horace Roman, MD, PhD, an endometriosis surgeon at the Endometriosis Center of the Clinic Tivoli-Ducos in Bordeaux, France.

The study comprised 52 women managed by Dr. Roman in three nearby referral centers, for deep endometriosis involving the sacral roots and the sciatic nerve from October 2016 to April 2019.

Deep endometriosis involved the sacral roots in 94.2% of cases and the sciatic nerve in the remaining 5.8% of cases. Sciatic pain (buttock or leg) was observed in 82.7% of cases, pudendal neuralgia in 21.2% and leg motor weakness in 27% of cases.

For surgical procedures of the pelvis nerves, Dr. Roman performed complete releasing and decompression in 48 patients (92.3%), excision of epineurium by shaving in three patients (5.8%) and intraneural excision in one patient (1.9%).

The digestive tract was involved in 82.7% of overall cases and the urinary tract in 46.2%. Rectovaginal fistula occurred in 13.5% of cases.

Self-catheterization was required in 27% of cases at 3 weeks after surgery and in 5.8% of cases at 1 year.

One-year follow up also showed significant improvement in quality of life using the 36-Item Short Form Survey (SF-36) and standardized gastrointestinal scores.

De novo hypoesthesia, hyperaesthesia or allodynia were recorded in 17.2% of cases.

After a mean follow up of 2 years, the cumulative pregnancy rate was 77.2%, with natural conception in 47% of these cases.

We were satisfied to observe a major improvement of patients’ overall quality of life and pain, as well as favorable fertility outcomes,” Dr. Roman told Contemporary OB/GYN. “However, we were surprised to discover that the impact of these large lesions was not confined to the sacral plexus, but also affected the low rectum, the vagina, the bladder and ureters in a majority of cases.”

These findings resulted in a complex surgical procedure, “where the dissection of pelvic nerves represented only one step of the surgery, and sometimes not the most challenging step,” Dr. Roman said. In addition, major unfavorable postoperative outcomes were related to both nerve dysfunction and complications related to other pelvic organs, particularly to low rectal fistulae.

Our study provides a good oversight on preoperative baseline complaints in patients with deep endometriosis involving the sacral plexus, as well as on standardized surgical procedures performed in these patients,” Dr. Roman said. “The study also estimated the probability of postoperative clinical improvement, plus the risk of major complications following this particular type of complex surgery.”

The data should be part of the information that patients receive preoperatively and will help with informed choice, according to Dr. Roman.

Furthermore, the study provides the basis to create a standardized step-by-step approach to deep endometriosis involving the sacral plexus, “which are reproducible and feasible in experienced hands, and prevents intraoperative complications,” Dr. Roman said.

Dr. Roman hopes the study will be followed by larger multicenter trials of experienced surgical teams from various countries to provide more detailed data on the reproducibility of complex surgeries worldwide and the risk of rare intraoperative or postoperative complications and their successful management.

Read more: https://www.jmig.org/article/S1553-4650(20)31107-9/abstract

Source: https://www.contemporaryobgyn.net/view/postoperative-outcomes-after-surgery-for-deep-endometriosis-of-sacral-plexus?utm_source=sfmc&utm_medium=email&utm_campaign=11_18_20_COG_SYN-19-COD0196_%20HOL-20-COP0108_COG_eNL_INTL_Only&eKey=anNvdXNzaXNAZ21haWwuY29t

MP’s call for urgent government action to support women with endometriosis

MP’s call for urgent government action to support women with endometriosis

The All-Party Political Group (APPG) published the findings of its inquiry into endometriosis.

The inquiry surveyed over 10,000 women with endometriosis in the UK and interviewed healthcare practitioners about their experiences.

The APPG is calling on all Governments in the UK to commit to a series of support measures for those with endometriosis including a commitment to reduce average diagnosis times to 4 years or less by 2025, and a year or less by 2030.

Dr Edward Morris, President of the Royal College of Obstetricians and Gynaecologists (RCOG), said:

This report is vital in understanding how women living with endometriosis in the UK continue to be let down when it comes to their diagnosis, treatment and the support they receive to manage their condition.

“While endometriosis costs the UK economy billions of pounds per year in treatment, loss of work and healthcare costs, the impact on women’s wellbeing and mental health is much greater.

“The long diagnosis times and poor patient experience could be attributed to the significant gap in data when it comes to women and girls. What the RCOG would like to see is medical research in this area prioritised to ensure they get the advice and treatment that’s right for them so they can lead happy and healthy lives.”

Endometrioma affects fertility parameters but not embryo quality

Endometrioma affects fertility parameters but not embryo quality

Researchers sought to investigate the effects of endometrioma and the impact of bilaterality on in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) outcomes.

A Turkish study has found that that presence of endometrioma in patients with endometriosis negatively impacts fertility parameters, but has no effect on embryo quality, clinical pregnancy rates (PR), or live birth rates (LBR).

The study in the Journal of Gynecology Obstetrics and Human Reproduction also concluded bilaterality does not influence any fertility parameters or pregnancy rates.

Done retrospectively, the researchers sought to investigate the effects of endometrioma and the impact of bilaterality on in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) outcomes.

A total of 159 women who underwent IVF/CSI cycles at Zekai Tahir Burak Women’s Health Education and Research Hospital in Ankara, Turkey, between March 2015 and March 2018, were recruited for the study.

Patients were divided into two groups: the study group (n = 73) of infertile women with either unilateral or bilateral ovarian endometrioma with any IVF indication; and the control group (n = 86) without endometrioma.

Basal follicle-stimulating hormone (FSH) levels and total gonadotropin doses used during ovarian stimulation were significantly higher and antral follicle count (AFC) was significantly lower in the study group compared to the control group.

But the differences in these variables between the unilateral (n = 43) and the bilateral (n = 30) endometrioma group were non-significant.

Anti-Müllerian hormone (AMH) levels for unilateral and bilateral endometrioma were also comparable: 1.4 ng/ML and 1.23 ng/mL, respectively.

However, the number of endometriomas > 4 cm was significantly higher in the bilateral than in the unilateral group.

The study also found that the number of dominant follicles at trigger day and total oocyte retrieved were significantly higher in the control group than in the study group. But when compared between the unilateral and the bilateral endometrioma group, these differences were insignificant.

Still, the number of metaphase II (MII) oocytes was significantly higher in the control group compared to the unilateral group, whereas the difference was non-significant between the control group and the bilateral group.

For all procedures, sperm was obtained via ejaculation, and there were no cycles cancelled in the control group. However, in the study group, 12 cycles were cancelled because fertilized embryos could not be procured: 6 cycles each from the unilateral and bilateral group.

There were also four patients in the study group with no dominant follicle development, two each from the unilateral and bilateral group.

In addition, there were eight total fertilization failures, four each from the two groups.

Given the higher cancelling rates, the prognosis for patients with endometrioma seems to be worse than in patients without endometrioma,” wrote the authors.

On the other hand, the number of embryos achieved and blastocysts obtained were similar between the three groups (no laterality, unilateral and bilateral), as were rates of pregnancy, live birth, and early pregnancy loss.

There was also no statistically significant difference between the control and the unilateral groups for all grades of embryo.

However, the number of grade 2 embryos was significantly lower in the bilateral group compared to the control group. But for blastocyst and grade 1 embryo numbers, the bilateral group had comparable findings to the other two groups.

Based on our results, we speculate that bilaterality doesn’t exert additional damage on ovarian reserve more than unilateral endometrioma does,” wrote the authors.

Read more: https://www.sciencedirect.com/science/article/abs/pii/S2468784720301835

Endometriosis fertility index predicts if a woman needs IVF

Endometriosis fertility index predicts if a woman needs IVF

The Endometriosis Fertility Index (EFI) is a good indicator for predicting pregnancy achieved without use of assisted reproductive technology (ART), according to a meta-analysis of 17 studies involving 4,598 women.

Patients with low Endometriosis Fertility Index (EFI) scores may not have a strong chance of a pregnancy achieved without use of assisted reproductive technology (ART), according to a meta-analysis from BJOG.

The Iranian authors of the review in BJOG noted that study results to evaluate the EFI score for predicting non-ART pregnancy have been inconsistent.

The cumulative rate of non-ART pregnancy at 36 months was 10% for women with an EFI of 0 to 2, which significantly increased to 69% for women with an EFI of 9 to 10. Furthermore, compared to women with an EFI of 3 to 4 combined cumulative non-ART pregnancies were 44% for women with an EFT of 5 to 6, and 55% for women with an EFI of 7 to 8. A significant difference existed between all categories.

The odds ratio (OR) for EFI was 1.33 and the summary area under the curve (AUC) was 72%.


The authors stated that the existing revised American Fertility Society (rAFS) score for staging endometriosis has considerable limitations, including arbitrary point scores and wide score ranges within the categories. There is also the “potential for observer error because of numerous morphological presentations, some subtle and microscopic and the timing of the laparoscopy, and whether the staging is performed at laparoscopy or laparotomy,” they wrote.

Furthermore, there is poor correlation between the extent of disease and pelvic pain and rAFS stages align poorly with infertility. For these and many other reasons, EFI has been proposed as having greater predictive power than rAFS for a successful pregnancy, with or without ART, in endometriosis patients.

Specifically, patients with an EFI score of 0 to 3 should be informed as to the low likelihood of non-ART pregnancy; therefore, ART should be strongly recommended.

Women unlikely to achieve non-ART pregnancy or spontaneous pregnancy, based on their EFI score, might be candidates for earlier in vitro fertilization and embryo transfer to prevent treatment delays and increase their chances for pregnancy.

The non-ART pregnancy rate might be linked with duration before attempting ART. For fertility management, EFI can be used as a predictive factor for a spontaneous second pregnancy.

Despite the review concluding that the EFI score is a good predictor for non-ART pregnancy, “these findings should be considered with caution due to the substantial heterogeneity between studies,” the authors said.

Read more: https://pubmed.ncbi.nlm.nih.gov/31967727/

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