Ovarian cancer risk associated with varying causes of infertility

OBJECTIVE: To evaluate the risk of ovarian cancer as related to underlying causes of infertility. DESIGN: Retrospective observational cohort study. SETTING: Five large reproductive endocrinology practices. PATIENT(S): A total of 12,193 women evaluated for infertility between 1965 and 1988. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Ovarian cancer ascertained through 1999. RESULT(S): With 45 identified ovarian cancers, this cohort of infertility patients demonstrated a significantly higher rate of ovarian cancer than the general female population (standardized incidence ratio [SIR] = 1.98; 95% confidence interval [CI], 1.4-2.6). The risk was higher for patients with primary infertility (SIR = 2.73) than for those with secondary infertility (SIR = 1.44), and it was particularly high for patients who never subsequently conceived (SIR = 3.33). Women with endometriosis had the highest risk (SIR = 2.48; 95% CI, 1.3-4.2), with a further elevated risk among those with primary infertility (4.19, 2.0-7.7). Comparisons among the infertile women, which allowed calculation of rate ratios (RRs) after adjustment for multiple factors, also showed links with endometriosis. Compared with women with secondary infertility without endometriosis, patients with primary infertility and endometriosis had a RR of 2.72 (95% CI, 1.1-6.7). CONCLUSION(S): Determination of ovarian cancer risk should take into account the type of infertility (primary vs. secondary) and underlying causes. Further study of endometriosis may provide insights into ovarian carcinogenesis.     

Oral contraceptive use, reproductive history, and risk of epithelial ovarian cancer in women with and without endometriosis

OBJECTIVE: Women with endometriosis may be at an increased risk of ovarian cancer. It is not known whether reproductive factors that reduce the risk of ovarian cancer in general also reduce risk in women with endometriosis. We investigated whether the odds ratios for ovarian cancer that were associated with oral contraceptive use, childbearing, hysterectomy, and tubal ligation differ among women with and without endometriosis. STUDY DESIGN: We pooled information on the self-reported history of endometriosis from 4 population-based case-controlled studies of incident epithelial ovarian cancer, comprising 2098 cases and 2953 control subjects. We obtained data on oral contraceptive use, childbearing, breastfeeding, gynecologic surgical procedures, and other reproductive factors on each woman. Multivariable unconditional logistic regression was used to calculate odds ratios and 95% CI for ovarian cancer among women with endometriosis compared with women without endometriosis. Similar methods were used to assess the frequencies of risk factors among women with and without endometriosis. Adjustments were made for age, parity, oral contraceptive use, tubal ligation, family history of ovarian cancer, and study site. RESULTS: Women with endometriosis were at an increased risk of ovarian cancer (odds ratio, 1.32; 95% CI, 1.06-1.65). Using oral contraceptives, bearing children, and having a tubal ligation or hysterectomy were associated with a similar reduction in the odds ratios for ovarian cancer among women with and without endometriosis. In particular, the use of oral contraceptives for >10 years was associated with a substantial reduction in risk among women with endometriosis (odds ratio, 0.21; 95% CI, 0.08-0.58). CONCLUSION: Women with endometriosis are at an increased risk of epithelial ovarian cancer. Long-term oral contraceptive use may provide substantial protection against the disease in this high-risk population.     

Risk Factors for Urologic Injury in Women Undergoing Hysterectomy for Benign Indication

ObjectiveTo investigate risk factors associated with urologic injury in women undergoing hysterectomy for benign indication.MethodsA retrospective cohort study for the period of 2011–2018 was conducted using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Women without urologic injury were compared with women with injury. A pre-specified multivariable logistic regression model, controlling for key patient demographic factors and intraoperative variables, was used to assess for surgical factors associated with urologic injury.ResultsAmong 262 117 women who underwent hysterectomy for benign indication, 1539 (0.6%) sustained urologic injury. On average, patients with urologic injury were younger, had lower body mass index (BMI), and more frequently underwent a transabdominal surgical approach. Patients who underwent total hysterectomy had increased odds of urologic injury than those who underwent subtotal hysterectomy (adjusted OR [aOR] 1.49; 95% confidence interval [CI] 1.21–1.84). Patients with class III obesity had lower odds of injury than patients with normal BMI (aOR 0.64; 95% CI 0.51–0.80). For risk of urologic injury, an interaction was observed between surgical approach and surgical indication. Abdominal compared with laparoscopic approach was associated with urologic injury for women with endometriosis (aOR 2.98; 95% CI 1.99–4.47), pelvic pain (aOR 3.51; 95% CI 1.74–7.08), menstrual disorders (aOR 4.33; 95% CI 1.68–11.1), and fibroids (aOR 2.28; 95% CI 1.72–3.03). Vaginal compared with laparoscopic approach was associated with increased odds of injury for women with menstrual disorders (aOR 7.62; 95% CI 1.37–42.5).ConclusionWhile the risk of urologic injury during hysterectomy for benign indication is low, the risk is dependent on patient disease factors and surgical approach.     

Cancer risk after hospital discharge diagnosis of benign ovarian cysts and endometriosis

BACKGROUND: The aim was to evaluate whether patients with benign ovarian cysts, functional ovarian cysts, or endometriosis have an increased risk of developing gynecologic cancer. METHODS: The Swedish Hospital Discharge Register was used to identify a cohort of women discharged from hospital with the diagnoses of ovarian cyst (n = 42217), functional ovarian cyst (n = 17998), or endometriosis (n = 28163). To each case, three controls were matched. The National Swedish Cancer Register matched all incident cancers diagnosed among cases and controls. From the Fertility Register, the date of birth of children born to the cases and controls were obtained. RESULTS: Women with endometriosis had an increased risk for ovarian cancer (OR 1.34; 95% CI 1.03-1.75), but no association was found between ovarian cysts or functional cysts and ovarian malignancy, including all ages. Young women (15-29 years old) discharged from hospital for ovarian cysts and functional cysts showed an increased risk of developing ovarian cancer later in life (OR 2.2; 95% CI 1.3-3.9 and OR 1.8; 95% CI 1.5-2.0), as well as women with ovarian cysts who had undergone ovarian cyst resection or unilateral oophorectomy (OR 8.8; 95% CI 5.2-15). The risk of developing ovarian cancer was inversely related to parity. Mean age at diagnosis was significantly lower in all three study groups. CONCLUSION: In this study women with endometriosis and young women who had undergone surgery with removal of an ovarian cyst had an increased risk of developing ovarian cancer.     

Minimally Invasive Radical Hysterectomy for Cervical Cancer: A Systematic Review and Meta-analysis

ObjectiveTo compare recurrence rate, progression-free survival (PFS), and overall survival for early-stage cervical cancer after minimally invasive (MIS) vs abdominal radical hysterectomy.Data SourcesMEDLINE, Embase, Cochrane Central Register of Controlled Trials, and Cochrane Library databases.Methods of Study SelectionWe identified studies from 1990 to 2020 that included women with stage I or higher cervical cancer treated with primary radical hysterectomy and compared recurrence and/or PFS and overall survival with MIS vs abdominal radical hysterectomy. (The review protocol was registered with the International Prospective Register of Systematic Reviews: CRD4202173600).Tabulation, Integration, and ResultsWe performed random-effects meta-analyses overall and by length of follow-up. Fifty articles on 40 cohort studies and 1 randomized controlled trial that included 22 593 women with cervical cancer met the inclusion criteria. Twenty percent of the studies had <36 months of follow-up, and 24% had more than 60 months of follow-up. The odds of PFS were worse for women undergoing MIS radical hysterectomy (odds ratio 1.54; 95% CI [confidence interval], 1.24–1.94; 14 studies). When limited to studies with longer follow-up, the odds of PFS were progressively worse with MIS radical hysterectomy (HR [hazard ratio] 1.48 for >36 months; 95% CI, 1.21–1.82; 10 studies; HR 1.69 for >48 months; 95% CI, 1.26–2.27; 5 studies; and HR 2.020 for >60 months; 95% CI, 1.36–3.001; 3 studies). For overall survival, the odds were not significantly different for MIS vs abdominal hysterectomy (odds ratio 0.94; 95% CI, 0.66–1.35; 14 studies) (HR 0.99 for >36 months; 95% CI, 0.66–1.48; 9 studies; HR 1.05 for >48 months; 95% CI, 0.57–1.94; 4 studies; and HR 1.35 for >60 months; 95% CI, 0.73–2.51; 3 studies).ConclusionIn our meta-analysis of 50 studies, MIS radical hysterectomy was associated with worse PFS than open radical hysterectomy for early-stage cervical cancer. The emergence of this finding with longer follow-up highlights the importance of long-term, high-quality studies to guide cancer and surgical treatments.     

Endometriosis and the subsequent risk of epithelial ovarian cancer

ObjectiveThere is a possible correlation between endometriosis and an increased risk of epithelial ovarian cancer (EOC), but many uncertainties remain, including race, exposure or surveillance time, and surgical confirmation. Therefore, we carried out a large-scale, nationwide, controlled cohort study in the Taiwanese women to respond to these uncertainties.Materials and methodsA historical cohort study was performed by linking the National Health Insurance Research Database of Taiwan. Each patient diagnosed with endometriosis (n = 7537) between 2000 and 2009 was background matched with up to two women without endometriosis (n = 15,074). The total was 136,643 person-years of follow-up and 24 women having new EOC. Cox regression analysis was used to determine the relationship between the EOC incidence rate and an endometriosis status.ResultsThe EOC incidence rate of the endometriosis and non-endometriosis women was 3.31 per 10,000 person-years and 0.99 per 10,000 person-years, respectively, contributing to an adjusted hazard ratio (HR) of 3.28 (95% confidence interval, 1.37–7.85). The women with surgical confirmation had a much higher adjusted HR (3.87; 95% confidence interval, 1.58–9.47). No significantly statistical difference of surveillance time between women with and without endometriosis (3.87 years vs. 3.73 years). The occurrence of EOC was not also affected by exposure time of women with endometriosis.ConclusionTaiwanese women with endometriosis really had a risk of newly developed EOC, especially those who had a surgical diagnosis, and this three-fold increase of risk was neither influenced by exposure time nor biased by surveillance.     

Risk Factors Associated with Adnexal Torsion after Hysterectomy

Study ObjectiveTo identify preoperative and intraoperative risk factors for adnexal torsion after hysterectomy, and to estimate the incidence of the disease in the modern-day era of laparoscopic surgery.DesignRetrospective nested case-control study.SettingLarge urban medical system.PatientsEighty-nine female patients ages 17 to 51.InterventionsPatients underwent ovarian-sparing hysterectomy.Measurements and Main ResultsThe estimated incidence of ovarian torsion after hysterectomy was 0.5% (46/8538 ovarian-sparing hysterectomies). The following variables were found to be associated with adnexal torsion after hysterectomy in an adjusted logistic regression: laparoscopic or laparoscopic-assisted approach to hysterectomy vs any other approach (odds ratio [OR], 3.36; 95% confidence interval [CI], 0.86–13.23); younger age at the time of hysterectomy (17–40 years) vs older age (41–51 years) (OR, 3.45; 95% CI, 1.33–8.97); and a gynecologic history significant for endometriosis (OR, 4.07; 95% CI, 1.04–15.88).ConclusionThere is an association between laparoscopic approach to hysterectomy, younger age at time of hysterectomy, and a history of endometriosis with subsequent risk of adnexal torsion. Providers should have a heightened index of suspicion for adnexal torsion after hysterectomy in patients presenting with acute-onset abdominal pain who underwent laparoscopic hysterectomy at a younger age.     

Cancer incidence in a cohort of infertile women who underwent in vitro fertilization

OBJECTIVE: To assess whether ovarian hyperstimulation and IVF increase the risk for cancer. DESIGN: Historical cohort analysis. SETTING; IVF units of two medical centers in Israel. PATIENT(S): Five thousand twenty-six women who underwent IVF between 1981 and 1992. INTERVENTION(S); Cancer incidence rates were determined through linkage to the National Cancer Registry and were compared with expected rates with respect to age, sex, and place of birth. MAIN OUTCOME MEASURE(S): Development of cancer. RESULT(S): Twenty-seven cases of cancer were observed, and 35.6 were expected (standardized incidence ratio, 0.76 [95% CI, 0.50-1.10]). Eleven cases of breast cancer were observed, whereas 15.86 were expected (standardized incidence ratio, 0.69 [95% CI, 0.46-1.66]). One case of ovarian cancer and 1 case of cervical cancer were observed, compared with 1.74 and 1.73 cases expected, respectively. The type of infertility, number of IVF cycles, and treatment outcome did not significantly affect risk for cancer. CONCLUSION(S): In a cohort of women treated with IVF, no excess risk for cancer was noted.     

Infertility, fertility drugs, and invasive ovarian cancer: a case-control study

Objective: To assess the risk of invasive ovarian cancer among infertile women treated with fertility drugs.

Design: A case-control study.

Setting: Nationwide data based on public registers.

Patient(s): All Danish women (below the age of 60 years) with ovarian cancer during the period from 1989 to 1994 and twice the number of age-matched population controls. Included in the analysis were 684 cases and 1,721 controls.

Main Outcome Measure(s): Influence of parity, infertility, and fertility drugs on the risk of ovarian cancer after multivariate confounder control. Risk measure(s): odds ratios (OR) with 95% confidence intervals.

Result(s): Nulliparous women had an increased risk of ovarian cancer compared with parous women: OR 1.5 to 2.0. Infertile, nontreated nulliparous women had an OR of 2.7 (1.3 to 5.5) compared with noninfertile nulliparous women. The OR of ovarian cancer among treated nulliparous women was 0.8 (0.4 to 2.0) and among treated parous 0.6 (0.2 to 1.3), compared with nontreated nulliparous and parous infertile women, respectively.

Conclusion(s): Nulliparity implies a 1.5- to 2-fold increased risk of ovarian cancer. Infertility without medical treatment among these women increased the risk further. Among parous as well as nulliparous women, treatment with fertility drugs did not increase the ovarian cancer risk compared with nontreated infertile women.     

Laser vaporization of ovarian endometriomas: the impact on the response to gonadotrophin stimulation

OBJECTIVE: To evaluate the ovarian response to stimulation for IVF in endometriosis patients who have previously undergone laparoscopic treatment of peritoneal and/or ovarian endometriosis (CO2 laser vaporization). PATIENTS AND METHODS: Retrospective study of 455 patients undergoing IVF. The study group, made up of 127 endometriosis patients, was divided into 2 subgroups: Ia: 42 women with peritoneal endometriosis, treated by laparoscopy, who underwent 71 IVF cycles; Ib: 85 women with ovarian endometriomas, treated by vaporization of the internal wall, who underwent 187 IVF cycles. The control group, consisting of 328 women, was also divided into 2 subgroups: IIa: 193 women suffering from tubal infertility who underwent 422 IVF cycles; IIb: 135 women with idiopathic infertility who underwent 275 IVF cycles. RESULTS: The ovarian stimulation parameters (number of gonadotrophin ampoules, number of follicles and mature oocytes, maximum estradiol concentrations) were not significantly different in the various subgroups. The number of embryos obtained and transferred per cycle, the fertilization rates (group Ia: 61.81%; Ib: 60.90%; IIa: 62.48%; IIb: 57.99%), the implantation rates (group Ia: 17.72%; Ib: 15%; IIa: 13.94%; IIb: 18.05%) and the clinical pregnancy rates (group Ia: 32.39%; Ib: 37.40%; IIa: 27.49%; IIb: 30.18%) were not statistically different in the studied subgroups. DISCUSSION AND CONCLUSION: The theoretical risk of loss of ovarian cortex when treating endometriotic cysts can be eliminated by the technique of vaporization of the internal wall of the endometrioma.IVF outcomes are similar in patients treated for endometriosis and those presenting with unexplained or tubal infertility.     

Effects of Obesity on Peri- and Postoperative Outcomes in Patients Undergoing Robotic versus Conventional Hysterectomy

Study ObjectiveTo assess if women with obesity have increased complication rates compared with women with normal weight undergoing hysterectomy for benign reasons and if the mode of hysterectomy affects the outcomes.DesignCohort study.SettingProspectively collected data from 3 Swedish population-based registers.PatientsWomen undergoing a total hysterectomy for benign indications in Sweden between January 1, 2015, and December 31, 2017. The patients were grouped according to the World Health Organization's classification of obesity.InterventionsIntraoperative and postoperative data were retrieved from the surgical register up to 1 year after the hysterectomy. Different modes of hysterectomy in patients with obesity were compared, such as open abdominal hysterectomy (AH), traditional laparoscopic hysterectomy (TLH), vaginal hysterectomy (VH), and robot-assisted laparoscopic hysterectomy (RTLH).Measurements and Main ResultsOut of 12,386 women who had a total hysterectomy during the study period, we identified 2787 women with normal weight and 1535 women with obesity (body mass index ≥30). One year after the hysterectomy, the frequency of complications was higher in women with obesity than in women with normal weight (adjusted odds ratio [aOR]) 1.4; 95% confidence interval [CI], 1.1–1.8). In women with obesity, AH was associated with a higher overall complication rate (aOR 1.8; 95% CI, 1.2–2.6) and VH had a slightly higher risk of intraoperative complications (aOR 4.4; 95% CI, 1.2–15.8), both in comparison with RTLH. Women with obesity had a higher rate of conversion to AH with conventional minimally invasive hysterectomy (TLH: aOR 28.2; 95% CI, 6.4–124.7 and VH: 17.1; 95% CI, 3.5–83.8, respectively) compared with RTLH. AH, TLH, and VH were associated with a higher risk of blood loss >500 mL than RTLH (aOR 11.8; 95% CI, 3.4–40.5; aOR 8.5; 95% CI, 2.5–29.5; and aOR 5.8; 95% CI, 1.5–22.8, respectively) in women with obesity.ConclusionThe use of RTLH may lower the risk of conversion rates and intraoperative bleeding in women who are obese compared with other modes of hysterectomy.     

The risk of poor ovarian response during repeat IVF

Research questionWhat are the incidence and risk factors for poor ovarian response (POR) during repeat IVF?DesignA retrospective analysis of 1224 consecutive patients who underwent at least two IVF stimulations in a single centre over a 6-year period. Risk factors from the initial treatment were assessed for association with POR during repeat IVF using logistic regression analysis. A simple, practical predictive model was constructed and evaluated for accuracy and calibration, based on the factors that demonstrated significant association with subsequent POR. POR during repeat IVF was defined as ≤3 retrieved oocytes or cancellation before retrieval following recruitment of ≤3 mature follicles.ResultsThe risk of POR during repeat IVF was approximately 11.5%. A higher POR risk during repeat IVF is associated with a reduced oocyte yield during the initial treatment (≤3 oocytes: odds ratio [OR] 14, 95% confidence interval [CI] 6.42–30.24; 4–9 oocytes: OR 4.13, 95% CI 2.00–8.54; 10–15 oocytes: OR 1) and low ovarian reserve (anti-Müllerian hormone [AMH] <5.4 pmol/l: OR 3.54, 95% CI 2.24–5.59; AMH 5.4–25 pmol/l: OR 1). Women with low ovarian reserve who experience POR during the initial IVF have the highest risk of suffering POR again during repeat IVF (57% within 1 year). Other groups, such as women with unexpected POR or expected poor responders with suboptimal ovarian response during the initial IVF, are also at risk of exhibiting POR during a subsequent treatment (28% within 1 year).ConclusionsAs there is a clear association between POR and lower live birth rates, this practical model may help manage patients’ expectations during repeat IVF treatment.     

Possible candidate population for neoadjuvant chemotherapy in women with advanced ovarian cancer

ObjectiveTo examine trends and outcomes related to neoadjuvant chemotherapy (NACT) use for advanced ovarian cancer based on patient and tumor factors.MethodsThis retrospective cohort study queried the National Cancer Institute's Surveillance, Epidemiology, and End Results Program to examine women with stage III-IV high-grade serous ovarian carcinoma from 2010 to 2016. Propensity score inverse probability of treatment weighting was used to assess the age-, cancer stage-, and tumor extent-specific survival estimates related to NACT use.ResultsUtilization of NACT has significantly increased in older women (≥65 years; 48.4% relative increase), followed by stage IV disease (35.2% relative increase), and stage III disease (25.0% relative increase) (all, P-trend < 0.05). Women who received NACT had overall survival (OS) similar to those who had primary cytoreductive surgery (PCS) in older women (hazard ratio [HR] 1.07, 95% confidence interval [CI] 0.95–1.20, P = 0.284), stage IV disease (HR 0.96, 95%CI 0.84–1.10, P = 0.564), and more disease extent cases (T3/N1/M1, HR 1.06, 95%CI 0.84–1.32, P = 0.640). Moreover, NACT use was associated with decreased other cause mortality risk compared to PCS in the older women (sub-distribution HR 0.61, 95%CI 0.40–0.94, P = 0.025) and stage IV disease (sub-distribution HR 0.49, 95%CI 0.27–0.90, P = 0.021). In contrast, women who received NACT had decreased OS compared to those who had PCS in the younger group (HR 1.22, 95%CI 1.07–1.38, P = 0.004), stage III disease (HR 1.26, 95%CI 1.13–1.41, P < 0.001), and lesser disease extent cases (T3/N0/M0, HR 1.38, 95%CI 1.20–1.58, P < 0.001).ConclusionOur study suggests that survival effect of NACT for advanced ovarian cancer may differ based on patient and tumor factors. In older women, stage IV disease, and greater disease extent, NACT was associated with similar OS compared to PCS.     

Fertility in patients with untreated rectosigmoid endometriosis

Research questionSeveral studies have investigated reproductive outcomes following surgical treatment of colorectal endometriosis, mainly segmental colorectal resection. This study examines pregnancy and live birth rates of women with rectosigmoid endometriosis not treated by surgery.DesignA retrospective analysis of data collected between May 2009 and January 2020 related to 215 women affected by rectosigmoid endometriosis wishing to conceive. Patients had a diagnosis of rectosigmoid endometriosis by transvaginal ultrasonography and magnetic resonance imaging enema. Patients with estimated bowel stenosis >70% at computed tomographic colonography and/or subocclusive/occlusive symptoms were excluded.ResultsDuring the median length of follow-up of 31 months (range 13–63 months), the total pregnancy and live birth rates of the study population were 47.9% and 45.1%, respectively. Sixty-two women had a live birth after natural conception (28.8%; 95% confidence interval [CI] 22.8–35.6%) with a median time required to conceive of 10 months (range 2–34 months). Eighty-three women underwent infertility treatments (38.6%, 95% CI 32.1–45.5%); among these, 68 patients underwent IVF either directly (n = 51) or after intrauterine insemination (IUI) failure (n = 17). Time to conception was significantly higher in women having conceived by IVF than in those having conceived naturally (P < 0.001) or by IUI (P = 0.006). In patients undergoing IVF cycles, a worsening of some pain and intestinal symptoms was observed.ConclusionsAt median follow-up of 31 months, women with rectosigmoid endometriosis have a 48% pregnancy rate. However, these patients must be referred to centres specialized in managing endometriosis to properly assess symptoms and degree of bowel stenosis.     

Type of Pelvic Disease as a Risk Factor for Surgical Site Infectionin Women Undergoing Hysterectomy

Study ObjectiveTo quantify the relationship between type of benign pelvic disease and risk of surgical site infection (SSI) after hysterectomy.DesignRetrospective cohort study (Canadian Task Force classification II-2).SettingHospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP).PatientsWomen who underwent hysterectomy from 2006-2015 and recorded in NSQIP database.InterventionNone.Measurements and Main ResultsSSI risk was compared for type of benign pelvic disease, patient characteristics (i.e., age, race, and selected comorbidities) and process of care variables (i.e., admission status, type of hysterectomy, and operative time). SSI occurred in 2.48% of the 125,337 women who underwent hysterectomy. SSI was most frequent in patients with endometriosis and least frequent in those with genital prolapse (3.13% vs 1.39%; p <.0001). Following adjustment for potential confounders, the odds of SSI were higher in women undergoing hysterectomy for endometriosis (adjusted odds ratio [aOR], 1.79; 95% confidence interval [CI], 1.43– 2.25), uterine myomas (aOR, 1.28; 95% CI, 1.05–1.55), menstrual disorders (aOR, 1.46; 95% CI, 1.20–1.78), and pelvic pain (aOR, 1.75; 95% CI, 1.34–2.27) compared with women undergoing hysterectomy for genital prolapse. Other patient factors associated with SSI included age, body mass index, smoking, diabetes mellitus, chronic obstructive pulmonary disease, hypertension, and American Society of Anesthesiologists classification. Among process-of-care factors, inpatient status, route of hysterectomy, total vs subtotal hysterectomy, and operative time were also associated with SSI.ConclusionIn addition to various patient and process-of-care factors known to be associated with SSI, type of underlying pelvic disease is an independent risk factor for SSI in women undergoing hysterectomy for benign indications.     

Evaluation of the efficacy of traditional Chinese medicine for the reproductive and pregnancy outcomes in women with endometriosis: A nationwide population-based study

ObjectivePatients with endometriosis may seek traditional Chinese medicine (TCM) to help them conceive. The present study aims to evaluate the effects of TCM on reproductive and pregnancy outcomes in patients with endometriosis.Materials and methodsThe patients with endometriosis taken from the National Health Insurance (NHI) research database between 2000 and 2012 were divided into two cohorts based on the use of TCM treatment. The two cohorts were matched by age and comorbidities and followed up until a new diagnosis of infertility, ectopic pregnancy, or miscarriage. Multivariable Cox proportional hazards models were used to evaluate the hazard ratio (HR) of reproductive and pregnancy outcomes.ResultsA total of 5244 patients with endometriosis were analyzed, including 1748 TCM users and 3496 matched control subjects. The proportion of infertility was higher in TCM users than in non-TCM users (adjusted hazard ratio [HR]: 1.34, 95% confidence interval [CI]: 1.13–1.60). However, there was no significant difference in the proportion of ectopic pregnancies between TCM users and non-TCM users (adjusted HR: 0.82, 95% CI: 0.60–1.13). There was no significant difference in the proportion of miscarriages between TCM users and non-TCM users (adjusted HR: 1.23, 95% CI: 0.95–1.61).ConclusionTCM treatment showed insignificant efficacy in decreasing the risk of ectopic pregnancy and miscarriage in patients with endometriosis.     

Impact of Surgery for Deep Infiltrative Endometriosis before In Vitro Fertilization: A Systematic Review and Meta-analysis

ObjectiveThe aims of this systematic review and meta-analysis were to compare reproductive outcomes in patients who underwent surgery for deep infiltrative endometriosis (DIE) before in vitro fertilization (IVF) with those in patients who underwent IVF without a previous surgery for DIE, to analyze data according to different types of surgery (complete or incomplete) or subgroups of patients (DIE with or without bowel involvement), and to assess surgical and IVF complications and data regarding safety concerns.Data SourcesA systematic literature search from January 1980 to November 2019 with no language restriction was performed in PubMed, MEDLINE, Embase, and Web of Science. The search strategy used the following Medical Subject Headings terms: “in vitro,” “fertilization,” “IVF,” “assisted reproduction,” “colorectal,” “endometriosis,” “deep,” “infiltrating,” “deep infiltrative endometriosis,” “intestinal,” “bowel,” “rectovaginal,” “uterosacral,” “vaginal,” and “bladder.”Methods of Study SelectionWe included studies that compared reproductive outcomes in women with infertility with DIE who received IVF with or without a previous surgery for DIE lesions. Meta-analysis was performed using Review Manager (RevMan v.5.3; Cochrane Training, London, United Kingdom). The risk of bias of the included studies was assessed using the method recommended by Cochrane Collaboration.Tabulation, Integration, and ResultsThe systematic search retrieved 150 articles; 98 studies were potentially eligible, and their full texts were reviewed. Of these, 12 studies met our inclusion criteria, and 5 presented data suitable for inclusion in a meta-analysis; however, 2 of the studies provided overlapping data, and only the larger study was finally included. No randomized controlled trials (RCTs) were found. The pregnancy rate per patient was 1.84 (95% confidence interval [CI], 1.28–2.64), the pregnancy rate per cycle was 1.84 (95% CI, 1.26–2.70), and the live birth rate per patient was 2.22 (95% CI, 1.42–3.46) times more likely for operated patients than for nonoperated ones. The addition of data from the incomplete surgery groups also showed a higher pregnancy rate per patient for surgery before IVF (odds ratio [OR] 1.63; 95% CI, 1.16–2.28). The results favor previous surgery in DIE with digestive involvement (OR 2.43; 95% CI, 1.13–5.22) and also in DIE without digestive involvement (OR 1.55; 95% CI, 0.61–3.95). A qualitative analysis of the complications of surgery and IVF showed a partial or complete lack of information on these issues as well as high heterogeneity in the reported data. None of these studies is an RCT; therefore, all have a high risk of selection and allocation bias, except for 1 study that statistically controlled the latter risk by using propensity scores. Funnel plots showed no asymmetry.ConclusionThe results were very consistent for all the studied outcomes, showing a statistically significant benefit for surgery before IVF, although they should be confirmed with RCTs. In addition to the reproductive outcomes, safety data should also be reported to obtain a complete assessment of the risks and benefits.     

The impact of IVF procedures on endometriosis recurrence

Objective

In infertile women with endometriosis requiring an in vitro fertilization (IVF) procedure, the potential risk of an IVF-related progression of the disease remains a matter of debate. Thus, since available data on this issue are scanty and controversial, an observational study has been herein conducted in order to clarify this issue.

Study design

We recruited 233 women with endometriosis who underwent IVF cycles in our unit. Patients were contacted to assess whether they experienced recurrences of the disease after IVF. The main outcome was to evaluate the impact of the number of IVF cycles and the responsiveness to ovarian hyperstimulation on the likelihood of recurrence. Clinical characteristics of women who did and did not have a recurrence were compared.

Results

One hundred and eighty-nine women were included, 41 of whom (22%) had a diagnosis of endometriosis recurrence. The 36 months cumulative recurrence rate was 20%. The number of IVF cycles and the responsiveness to ovarian hyperstimulation were not associated with the risk of disease recurrence. The adjusted OR for recurrences according to the number of started cycles was 0.92 (95% CI: 0.77–1.10) per cycle (p = 0.35). The adjusted OR for recurrences in women with intact versus compromised ovarian reserve was 0.80 (95% CI: 0.40–1.58) (p = 0.52).

Conclusions

IVF procedures do not seem to influence the likelihood of endometriosis recurrence.     

Risk of Upper-body Adverse Events in Robot-assisted Total Laparoscopic Hysterectomy for Benign Gynecologic Disease

Study ObjectiveRecent studies suggest that prolonged Trendelenburg positioning during robot-assisted total laparoscopic hysterectomy (RA-TLH) may lead to fluid shifts and pulmonary, airway, head and neck, and cranial complications in the upper body. This study examined the upper-body complications during RA-TLH for benign gynecologic disease.DesignPopulation-based retrospective study.SettingThe National Inpatient Sample.PatientsA total of 771 412 women who had total hysterectomy for benign gynecologic disease from October 2008 to September 2015, including 661 284 women who had total abdominal hysterectomy (TAH), 51 544 women who had traditional TLH, and 58 584 women who had RA-TLH.InterventionsA multiple-group generalized boosted model to balance the measured baseline covariates across the 3 hysterectomy groups and a generalized estimating equation model to assess the effect size of complication risk (overall and upper-body complications).Measurements and Main ResultsWomen in the RA-TLH group were more likely to be older, white, and have a higher comorbidity index (all, p <.001). The overall rate of upper-body complications was 4.6% across the 3 groups. RA-TLH was not associated with increased risk of upper-body complications compared with traditional TLH (odds ratio [OR] 1.06; 95% confidence interval [CI], 0.90–1.26) or TAH (OR 0.98; 95% CI, 0.87–1.11). In contrast, RA-TLH was associated with decreased risk of overall perioperative complications compared with TAH (12.0% vs 18.6%; OR 0.64; 95% CI, 0.59–0.70; p <.001). RA-TLH and traditional TLH had similar risk of overall perioperative complications (12.0% vs 13.1%; OR 0.91; 95% CI, 0.8–1.02; p = .099). Women who developed upper-body complications had a higher perioperative mortality rate (0.4% vs <0.01%; OR 79.1; 95% CI, 36.0–174). The highest rates of complications (62.5%) were observed in morbidly obese women aged 70–79 with a comorbidity index of ≥4.ConclusionIn hysterectomy for benign gynecologic disease, RA-TLH was not associated with an increased risk of upper-body complications compared with TAH or traditional TLH. However, older age and higher comorbidity are key risk factors that increase the risk of upper-body complications which carry a disproportionally high mortality rate.