Surgical Outcomes after Colorectal Surgery for Endometriosis: A Systematic Review and Meta-analysis

ObjectiveTo assess the impact of type of surgery for colorectal endometriosis—rectal shaving or discoid resection or segmental colorectal resection—on complications and surgical outcomes.Data SourcesWe performed a systematic review of all English- and French-language full-text articles addressing the surgical management of colorectal endometriosis, and compared the postoperative complications according to surgical technique by meta-analysis. The PubMed, Clinical Trials.gov, Cochrane Library, and Web of Science databases were searched for relevant studies published before March 27, 2020. The search strategy used the following Medical Subject Headings terms: (“bowel endometriosis” or “colorectal endometriosis”) AND (“surgery for endometriosis” or “conservative management” or “radical management” or “colorectal resection” or “shaving” or “full thickness resection” or “disc excision”) AND (“treatment”, “outcomes”, “long term results” and “complications”).Methods of Study SelectionTwo authors conducted the literature search and independently screened abstracts for inclusion, with resolution of any difference by 3 other authors. Studies were included if data on surgical management (shaving, disc excision, and/or segmental resection) were provided and if postoperative outcomes were detailed with at least the number of complications. The risk of bias was assessed according to the Cochrane recommendations.Tabulation, Integration, and ResultsOf the 168 full-text articles assessed for eligibility, 60 were included in the qualitative synthesis. Seventeen of these were included in the meta-analysis on rectovaginal fistula, 10 on anastomotic leakage, 5 on anastomotic stenosis, and 9 on voiding dysfunction <30 days. The mean complication rate according to shaving, disc excision, and segmental resection were 2.2%, 9.7%, and 9.9%, respectively. Rectal shaving was less associated with rectovaginal fistula than disc excision (odds ratio [OR] = 0.19; 95% confidence interval [CI], 0.10–0.36; p <.001; I² = 33%) and segmental colorectal resection (OR = 0.26; 95% CI, 0.15–0.44; p <.001; I² = 0%). No difference was found in the occurrence of rectovaginal fistula between disc excision and segmental colorectal resection (OR = 1.07; 95% CI, 0.70–1.63; p = .76; I² = 0%). Rectal shaving was less associated with leakage than disc excision (OR = 0.22; 95% CI, 0.06–0.73; p = .01; I² = 86%). No difference was found in the occurrence of leakage between rectal shaving and segmental colorectal resection (OR = 0.32; 95% CI, 0.10–1.01; p = .05; I² = 71%) or between disc excision and segmental colorectal resection (OR = 0.32; 95% CI, 0.30–1.58; p = .38; I² = 0%). Disc excision was less associated with anastomotic stenosis than segmental resection (OR = 0.15; 95% CI, 0.05–0.48; p = .001; I² = 59%). Disc excision was associated with more voiding dysfunction <30 days than rectal shaving (OR = 12.9; 95% CI, 1.40–119.34; p = .02; I² = 0%). No difference was found in the occurrence of voiding dysfunction <30 days between segmental resection and rectal shaving (OR = 3.05; 95% CI, 0.55–16.87; p = .20; I² = 0%) or between segmental colorectal and discoid resections (OR = 0.99; 95% CI, 0.54–1.85; p = .99; I² = 71%).ConclusionColorectal surgery for endometriosis exposes patients to a risk of severe complications such as rectovaginal fistula, anastomotic leakage, anastomotic stenosis, and voiding dysfunction. Rectal shaving seems to be less associated with postoperative complications than disc excision and segmental colorectal resection. However, this technique is not suitable for all patients with large bowel infiltration. Compared with segmental colorectal resection, disc excision has several advantages, including shorter operating time, shorter hospital stay, and lower risk of postoperative bowel stenosis.     

Voiding Dysfunction after Colorectal Surgery for Endometriosis: A Systematic Review and Meta-analysis

ObjectiveSurgical management of deep endometriosis is associated with a high incidence of lower urinary tract dysfunction. The aim of the current systematic review and meta-analysis was to assess the rates of voiding dysfunction according to colorectal shaving, discoid excision, and segmental resection for deep endometriosis.Data SourcesWe performed a systematic review using bibliographic citations from PubMed, Clinical Trials.gov, Embase, Cochrane Library, and Web of Science databases. Medical Subject Headings terms for colorectal endometriosis and voiding dysfunction were combined and restricted to the French and English languages. The final search was performed on August 28, 2019. The outcome measured was the occurrence of postoperative voiding dysfunction.Methods of Study SelectionStudy Quality Assessment Tools were used to assess the quality of included studies. Studies rated as good and fair were included. Two reviewers independently assessed the quality of each included study, discrepancies were discussed; if consensus was not reached, a third reviewer was consulted.Tabulation, Integration and ResultsOut of 201 relevant published reports, 51 studies were ultimately reviewed systematically and 13 were included in the meta-analysis. Rectal shaving was statistically less associated with postoperative voiding dysfunction than segmental colorectal resection (Odds ratio [OR] 0.34; 95% confidence intervals [CI], 0.18–0.63; I² = 0%; p <.001) or discoid excision (OR 0.22; 95% CI, 0.09–0.51; I² = 0%; p <.001). No significant difference was noted when comparing discoid excision and segmental colorectal resection (OR 0.74; 95% CI, 0.32–1.69; I² = 29%; p = .47). Similarly, rectal shaving was associated with a lower risk of self-catheterization >1 month than segmental colorectal resection (OR 0.3; 95% CI, 0.14–0.66; I² = 0%; p = .003). This outcome was no longer significant when comparing discoid excision and segmental colorectal resection (OR 0.72; 95% CI, 0.4–1.31; I² = 63%; p = .28).ConclusionColorectal surgery for endometriosis has a significant impact on urinary function regardless of the technique. However, rectal shaving causes less postoperative voiding dysfunction than discoid excision or segmental resection.     

Association between Endometriosis and Risk of Preeclampsia in Women Who Conceived Spontaneously: A Systematic Review and Meta-analysis

ObjectiveTo evaluate the association between endometriosis and the risk of preeclampsia and other maternal outcomes in spontaneously conceived women.Data SourcesPubMed, MEDLINE, Embase, Scopus, Cochrane Library, Web of Science, and Google Scholar were systemically searched for studies published from inception to November 2021 (CRD42020198741). Observational studies published in English or French that investigated the risk of preeclampsia in women with endometriosis who conceived spontaneously were included.Methods of Study SelectionA total of 610 articles were reviewed once duplicates were removed. Inclusion criteria included spontaneous conception and surgical and/or imaging ascertainment of an endometriosis diagnosis. Exclusion criteria included conception using assisted reproductive technologies, multiple pregnancies, chronic hypertension, and unclear diagnoses of endometriosis.Tabulation, Integration, and ResultsData of selected studies were extracted, and analysis was performed on Review Manager, version 5.4. Quality assessment of included studies for potential risk of bias was evaluated using the Newcastle-Ottawa Scale for cohort studies. Three cohort studies of spontaneous pregnancies were included. Endometriosis was associated with an increased risk of preeclampsia (risk ratio [RR] = 1.47, 95% CI 1.13 -1.89, p = .003; I² = 0%; n = 3 studies). A sensitivity analysis excluding a study with adenomyosis cases yielded similar risk (RR = 1.44; 95% CI, 1.11–1.87; p = .006; I² = 0%; n = 2 studies). Having endometriosis did not significantly increase risk of cesarean delivery (RR = 1.38; 95% CI, 0.99–1.92; p = .06; I² = 80%; n = 2 studies) or postpartum hemorrhage (RR = 1.16; 95% CI, 0.46–2.91; p = .76; I² = 50%; n = 2 studies).ConclusionWe detected an increased risk of preeclampsia in women with endometriosis who conceived spontaneously. Endometriosis did not seem to increase the risk of cesarean delivery and postpartum hemorrhage, but the number of studies was limited, and the heterogeneity was high.     

Recurrence after Surgery for Colorectal Endometriosis: A Systematic Review and Meta-analysis

ObjectiveThe recurrence rate after colorectal surgery for endometriosis is up to 50% at 5 years. The aim of the current review and meta-analysis was to assess recurrence associated with shaving, disc excision, and segmental resection for endometriosis with colorectal involvement.Data SourcesA systematic review was performed by searching the PubMed, ClinicalTrials.gov, EMBASE, Cochrane Library, and Web of Science databases for publications before February 28, 2019, using the terms “colorectal endometriosis” and “recurrence” in English. The outcome measure was histologically proven recurrence 1 year after the index surgery.Methods of Study SelectionStudies rated as good or fair by a study quality assessment tool were included. Two reviewers independently assessed the quality of the studies; discrepancies were discussed, and if a consensus was not reached, a third reviewer was consulted.Tabulation, Integration, and ResultsOf 156 relevant published trials, 41 were systematically reviewed and 4 were included in the meta-analysis. The risk of recurrence was higher after rectal shaving than after both segmental resection (odds ratio [OR], 5.53; 95% confidence interval [CI], 2.33–13.12; I² = 0%; p = .001) and disc excision for histologically proven recurrence (OR, 3.83; 95% CI, 1.33–11.05; I² = 0%; p = .01). This difference was not significant when comparing disc excision with segmental resection (OR, 2.63; 95% CI, 0.8–8.65; I² = 0%; p = .11).ConclusionThe current analysis shows that the risk of recurrence is lower when segmental resection or disc excision is performed than when rectal shaving is performed. This finding is important when deciding the most appropriate surgical management.     

Factors Predicting Persistent Ectopic Pregnancy After Laparoscopic Salpingostomy or Salpingotomy for Tubal Pregnancy: A Retrospective Cohort Study

Study ObjectiveTo identify factors predictive of persistent ectopic pregnancy (PEP) in women who have undergone laparoscopic salpingostomy or salpingotomy for tubal pregnancy.DesignRetrospective cohort study (Canadian Task Force classification II-2).SettingTertiary referral center.PatientsNinety-nine women who underwent laparoscopic tubal preservation surgery for ectopic pregnancy.InterventionsSeventy women underwent laparoscopic salpingostomy, and the remaining 29 women underwent laparoscopic salpingotomy.Measurements and Main ResultsFactors predicting PEP were evaluated. The change in serum beta human chorionic gonadotropin (β-hCG) levels from baseline observed between postoperative days 5 and 10 (ChCGD5-10) was a predictor of PEP (odds ratio [OR], 0.80; p = .01). Based on receiver operating characteristic (ROC) curve analysis, a cutoff value of 93.1% was determined, with an area under the ROC curve of 0.95 (sensitivity, 85.7%; specificity, 100%). Nonetheless, when considering perioperative variables only, body mass index (BMI) was identified as a predictor of PEP (OR, 0.71; p = .03). Based on the ROC analysis, a BMI cutoff value of ≤22 kg/m² was determined, with an ROC area of 0.73 (sensitivity, 43.2%; specificity, 100%). In addition, a higher baseline β-hCG level (hazard ratio [HR], 1.0002; p = .009) and left tubal pregnancy (HR, 6.46; p = .03) were predictive of recurrent ectopic pregnancy. There were no differences in the perioperative outcomes, PEP rates, or subsequent intrauterine pregnancy rates between the salpingostomy and salpingotomy groups. In addition, surgical method was not a predictor of recurrent ectopic pregnancy.ConclusionsChCGD5-10 was identified as a predictor for PEP, suggesting that it might be more clinically useful for the follow-up of PEP. When considering perioperative variables only, BMI was a predictor for PEP. In addition, there was no significant difference in clinical outcomes between the salpingostomy and salpingotomy groups.     

Endometriosis and gestational diabetes mellitus risk: a systematic review and meta-analysis

Objective: To perform a systematic review and meta-analysis regarding endometriosis and the risk of gestational diabetes mellitus (GDM).

Methods: We carried out a search of the following databases: Medline, Embase, Web of Science, Cochrane Library, Scopus, Scielo, Clinicaltrials.gov, the UK Clinical Trials Gateway, and the Australian New Zealand Clinical Trials Registry, from inception through April 28 2017, without language restrictions, in order to evaluate the effect of endometriosis over GDM risk, in women with and without endometriosis. Odds ratios (ORs) and their 95% confidence intervals (CIs) or mean differences (MDs) were calculated as effects. Methodological quality of evidence was assessed with the Newcastle–Ottawa Scale, and heterogeneity among studies with the I² statistic. Random-effects models were used for meta-analyses, and publication bias was assessed with Egger’s test.

Results: We identified 12 studies (10 cohort and two case control studies) with a total of 48,762 pregnancies, including 3,461 with endometriosis. Endometriosis had no significant effect on GDM risk (OR =1.14; 95% CI: 0.86, 1.51; p?=?.35, I²?=?56%, Egger’s test p?=?.45). Secondary outcomes (gestational age at delivery, birthweight, and Neonatal Intensive Care Unit admission) were statistically similar in women with and without endometriosis.

Conclusions: Better-designed studies are needed to confirm our results.     

Population-Based Study on the Effect of Socioeconomic Factors and Race on Management and Outcomes of 35,535 Inpatient Ectopic Pregnancies

Study ObjectiveTo evaluate whether socioeconomic variables influence the management and outcomes of ectopic pregnancies.DesignRetrospective cohort study (Canadian Task Force classification II-2).SettingHospitals in the United States participating in the Health Care Cost and Utilization Project.PatientsWomen (n = 35 535) with a primary discharge diagnosis of ectopic pregnancy.InterventionsEffect of socioeconomic factors and race/ethnicity on management and adverse outcomes of ectopic pregnancy.Measurements and Main ResultsDuring the 9-year study, 35 535 ectopic pregnancies were identified. The development of hemoperitoneum in 8706 patients (24.50%) was the most common complication. Asian race was the sociodemographic variable most predictive of hemoperitoneum (odds ratio [OR], 1.41; 95% confidence interval [CI], 1.24–1.61; p < .01) and transfusion (OR, 1.62; 95% CI, 1.39–1.89; p < .01), and Medicare status was most influential on prolonged hospitalization (OR, 1.83; 95% CI, 1.36–2.47; p < .01). Major complications were not affected by socioeconomic factors. Laparotomy in 25 075 patients (70.6%) was the most common treatment option. Patients of Asian or Pacific Islander descent were least likely to be treated non-surgically (OR, 0.62; 95% CI, 0.51–0.76; p < .01), whereas Medicare recipients were most likely to be treated non-surgically (OR, 1.70; 95% CI, 1.32–2.18; p < .01). All non-white groups were less likely to undergo a laparoscopic approach.ConclusionMajor complications from ectopic pregnancy are not influenced by socioeconomic variables; however, less serious complications and management approaches are persistently affected.     

The uterine leiomyoma and placenta previa: a meta-analysis

Background: Some epidemiological studies have reported that uterine leiomyoma may increase the risk of placenta previa. To date, the meta-analysis has not been carried out for assessing the relationship between uterine leiomyoma and placenta previa. This meta-analysis was carried out to estimate the association between uterine leiomyoma and the risk of placenta previa.

Methods: A systematic search was conducted out in major databases PubMed, Web of Science, and Scopus from the earliest possible year to June 2017. The heterogeneity across studies was explored by Q-test and I² statistic. The publication bias was assessed by Begg’s and Egger’s tests. The results were showed using odds ratio (OR) estimate with its 95% confidence intervals (CI) using a random-effects model.

Results: The literature search included 1218 articles until to June 2017 with 255,886 women. Based on OR estimates obtained from case-control and cohort studies, there was significant association between uterine leiomyoma and placenta previa in studies adjusted (2.21; 95%CI: 1.48, 2.94).

Conclusions: We showed based on reports in observational studies that uterine leiomyoma is a risk factor for placenta previa in studies adjusted.     

The association between body mass index and preeclampsia: a meta-analysis

Background: Several observational studies have reported a positive association between elevated body mass index (BMI) and preeclampsia, but no meta-analysis has been conducted yet. This meta-analysis was conducted to estimate the overall association between overweight or obesity and preeclampsia.

Methods: Major electronic databases, including PubMed, Web of Science, and Scopus were searched until August 2015. The reference lists of included studies were screened as well. Epidemiological studies addressing the association between BMI and preeclampsia were enrolled. The heterogeneity across studies was explored by Q-test and I² statistic. The possibility of publication bias was assessed using Begg's and Egger's tests. The results were reported using odds ratio (OR) estimate with its 95% confidence intervals (CI) using a random-effects model.

Results: We identified a total of 1298 references and included 23 studies with 1 387 599 participants. Preeclampsia was associated with overweight (OR?=?1.73; 95% CI: 1.59, 1.87; 21 studies; I^2?=^?62.3%) and obesity (OR?=?3.15; 95% CI: 2.96, 3.35; 22 studies; I^2?=^?36.0%). There was no evidence of publication bias.

Conclusions: There is sufficient evidence that excess body mass index is significantly associated with an increased risk of preeclampsia. Therefore, overweight and obesity can be considered as a predictor of preeclampsia.     

Impaired implantation in endometriosis compared with couples with male subfertility after transfer of equal quality embryos: a matched cohort study

Research questionIs implantation impaired in patients with endometriosis undergoing IVF and intracytoplasmatic sperm injection (ICSI) cycles?DesignA retrospective matched cohort study was carried out on IVF/ICSI cycles with fresh single embryo transfer at the Department of Assisted Reproductive Medicine, Ghent University Hospital, Belgium, between July 2015 and August 2017 (n = 1053). A total of 118 endometriosis cases were matched 1:1 to 118 couples diagnosed with male subfertility and stratified by embryo quality (identical ALPHA grading categories), female age (±1 year) and parity (±1 delivery). Transvaginal ultrasound, magnetic resonance imaging or laparoscopy was used to diagnosed endometriosis, and the revised American Society for Reproductive Medicine score was used to classify the endometriosis into grade I/II versus grade III/IV. Male subfertility was defined in accordance with World Health Organization criteria (fifth edition).ResultsCompared with endometriosis cases, control couples with male subfertility had significantly higher rates of positive HCG test on day 16 (P = 0.047, OR 2.077, CI 1.009 to 4.276), ongoing implantation (defined as a positive fetal heart rate on transvaginal ultrasound at a gestational age of at least 6.5–7 weeks) (P = 0.038, OR 2.265, CI 1.048 to 4.893), ongoing pregnancy (defined by a vital pregnancy at 11 weeks) (P = 0.046, OR 2.292, CI 1.016 to 5.173) and live birth (P = 0.043, OR 2.502, CI 1.029 to 6.087).ConclusionsAfter matching for embryo quality, woman's age and parity, rates of positive HCG tests, ongoing implantation, ongoing pregnancy and live birth were more than twice as high in the control group compared with the endometriosis group.     

A Systematic Review and Meta-analysis of Surgical Treatment of Ectopic Pregnancy with Salpingectomy versus Salpingostomy

ObjectiveTo evaluate the fertility outcomes of salpingectomy compared with those of salpingostomy among patients treated for tubal ectopic pregnancies, including a separate analysis of women with risk factors along with a review of the surgical technique.Data SourcesSystematic review and meta-analysis from 1990 to the present through PubMed, Embase, CINAHL, and Ovid MEDLINE. The search string included “tubal pregnancy” or “ectopic” as well as “salpingectomy” and various terms describing salpingotomy.Methods of Study SelectionArticles studying women who underwent surgical management of an ectopic pregnancy and the contrasted outcomes of salpingectomy vs salpingostomy were reviewed. The primary outcomes included subsequent intrauterine pregnancy (IUP) and repeat ectopic pregnancy (REP).Tabulation, Integration, and ResultsTwo randomized controlled trials (RCTs), which consisted mostly of patients classified as low risk, and patients from 16 cohort studies were included. In the RCTs, there was no significant difference in the odds of subsequent IUP in patients who underwent a salpingectomy compared with those who were treated with salpingotomy (odds ratio [OR] 0.97; 95% confidence interval [CI], 0.71–1.33). However, a significant and clinically meaningful difference was noted in the cohort studies, with the patients having a lower chance of IUP after salpingectomy (OR 0.45; 95% CI, 0.39–0.52). No significant difference was noted in the OR for a REP in the randomized trials (OR 0.77; 95% CI, 0.41–1.47), but the patients followed in the cohort studies had a cumulatively higher risk of REP after a salpingostomy (OR 0.73; 95% CI, 0.60–0.90).The subgroup analysis examining women within the studies with risk factors for tubal pathology found an even more impressive lowering in the odds of a subsequent IUP in patients classified as at-risk who were treated with salpingectomy (OR 0.30; 95% CI, 0.17–0.54), with a change in the direction of the odds for an REP rate favoring those who were treated with salpingostomy (OR 1.96; 95% CI, 0.88–4.35).ConclusionSalpingectomy has clear advantages over salpingostomy, and RCTs consisting mainly of patients classified as low risk show no difference in outcomes between salpingectomy and salpingostomy. However, in cohort studies inclusive of all patients, the likelihood of a subsequent spontaneous IUP is decreased in patients treated with salpingectomy, and salpingostomies may be especially underused in women with risk factors for tubal disease.     

Recurrent Tubal Ectopic Pregnancy Management and the Risk of a Third Ectopic Pregnancy

Study ObjectiveTo evaluate the rate of a third ectopic pregnancy according to the modality of treatment of the second ectopic pregnancy.DesignRetrospective cohort study.SettingUniversity-affiliated tertiary medical center.PatientsOne hundred eleven women who had 2 ectopic pregnancies and a third consecutive pregnancy between 2003 and 2018.InterventionsSurgery or medical treatment as required.Measurements and Main ResultsWith regard to the modality of treatment of the second ectopic pregnancy, the patients were divided into 3 groups: expectant management, medical treatment with methotrexate, and laparoscopic salpingectomy. Univariate and multivariate analyses were conducted to assess the association of various parameters of the second ectopic pregnancy with the occurrence of a third ectopic pregnancy in the consecutive pregnancy. Twenty women (18.0%) were managed expectantly, 55 (49.6%) were treated with methotrexate, and 36 (32.4%) underwent surgery. Expectant management resulted in significantly higher rates of a third ectopic pregnancy compared with treatment with methotrexate or surgical intervention (50.0% vs 18.2% and 13.8%, respectively; p = .005). In the cases of 2 ipsilateral ectopic pregnancies, the interventional approach (medical or surgical treatment) resulted in lower recurrence rates compared with expectant management (25.7% vs 60.0%, respectively; p = .043).ConclusionThe risk of a third episode of an ectopic pregnancy after expectant management of a second ectopic pregnancy is extremely high. An interventional approach by treatment with methotrexate or salpingectomy is therefore preferred for recurrent ectopic pregnancy management, especially in ipsilateral recurrences.     

The association between uterine leiomyoma and placenta abruption: A meta-analysis

Background: Some epidemiological studies have found that uterine leiomyoma can increase the risk of placenta abruption. To date, the meta-analysis has not been performed for assessing the relationship between uterine leiomyoma and placenta abruption. This meta-analysis was conducted to estimate the association between uterine leiomyoma and the risk of placenta abruption.

Methods: A literature search was conducted out in major databases PubMed, Web of Science, and Scopus from the earliest possible year to October 2016. The heterogeneity across studies was explored by Q-test and I² statistic. The publication bias was assessed by Begg's and Egger's tests. The results were showed using odds ratio (OR) estimate with its 95% confidence intervals (CI) using a random-effects model.

Results: The literature search included 953 articles until October 2016 with 232,024 participants. Based on OR estimates obtained from case–control and cohort studies, there was significant association between uterine leiomyoma and placenta abruption (2.63; 95% CI: 1.38, 3.88).

Conclusions: We showed based on reports in observational studies that uterine leiomyoma is a risk factor for placenta abruption.     

Influence of early-life factors on the development of endometriosis

Objective: Our aim was to study the association between early-life factors and the development of endometriosis.

Methods: This case–control study included 440 women with surgically confirmed endometriosis (cases) and 880 women without endometriosis (controls). Information on early-life factors was ascertained retrospectively by in-person interviews with participants and their mothers. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for the associations between endometriosis and maternal and paternal characteristics and foetal and infant exposures were estimated using unconditional logistic regression, adjusting for frequency matching and confounding variables.

Results: We observed that women who were not breastfed as infants had twice the risk of endometriosis compared with women who were breastfed (adjusted OR 2.0; 95% CI 1.6, 4.5). Our data suggested an increased endometriosis risk with neonatal vaginal bleeding (adjusted OR 1.9; 95% CI 1.2, 4.3) and paternal smoking (adjusted OR 1.8; 95% CI 1.1, 4.9). Although the CIs included the null hypothesis value, caesarean section (adjusted OR 1.7; 95% CI 1.0, 3.5) and prematurity (adjusted OR 1.4; 95% CI 0.8, 3.7) were probably associated with the incidence of endometriosis.

Conclusions: Some early-life factors including breastfeeding, neonatal vaginal bleeding and paternal smoking were associated with subsequent, surgically confirmed endometriosis in this cohort of Chinese women.     

Effect of Methotrexate on Salpingostomy Completion Rate for Tubal Ectopic Pregnancy: A Retrospective Cohort Study

Study ObjectiveTo determine whether completion rates of salpingostomy for tubal ectopic pregnancy are compromised by initial medical management with methotrexate (MTX).DesignRetrospective cohort study.SettingSingle academic hospital system.PatientsPatients requiring surgery for ectopic pregnancy between 2006 and 2017.InterventionsA subset of patients who went directly to surgery, and all patients who failed MTX before requiring surgery underwent detailed chart review. Salpingostomy plan and success rate and salpingostomy failure reasons were compared between patients pretreated with MTX and those who were MTX-untreated.Measurements and Main ResultsAmong 94 ectopic pregnancies requiring surgery after failed MTX treatment, 55 (59%) underwent planned salpingostomy. From 693 ectopic pregnancies managed without MTX, 166 were analyzed in detail, of which 80 (48%) underwent planned salpingostomy.The patients who underwent planned salpingostomy were thinner (body mass index 27.3 ± 7.2 kg/m² vs 29.3 ± 8.3 kg/m²; p = .048), less frequently African American (33% vs 47%; p = .017), and more likely to have a visualized adnexal lesion (70% vs 52%; p = .004) than those undergoing planned salpingectomy. Preoperative ultrasound identified fetal cardiac activity and hemoperitoneum at comparable rates.MTX exposure was not associated with age, body mass index, race, ectopic risk factors, human chorionic gonadotropin levels, or gestational age at diagnosis, but the patients treated with MTX underwent surgery later than those who were untreated (gestational age 53.4 ± 11.2 days vs 43.5 ± 11 days; p <.001). The differences between the adnexal lesion size and rates of fetal cardiac activity and hemoperitoneum on ultrasound related to MTX exposure did not meet significance. Planned salpingostomy was completed in 22 (40%) of the patients treated with MTX vs 34 (42%) of those who were untreated. The reasons for failure, surgery time, and rates of hemoperitoneum or ectopic rupture were not associated with MTX exposure.Body mass index, race, tubal anastomosis history, visualization of the adnexal lesion, and MTX exposure were not significantly associated with the salpingostomy rate in a multivariate logistic regression model, but having a subspecialist surgeon (odds ratio 2.70; 95% confidence interval, 1.08–6.76; p = .033) and tubal rupture at surgery (odds ratio 0.23; 95% confidence interval, 0.09–0.54; p = .001) were.ConclusionThe initial medical management of an ectopic pregnancy with MTX is not associated with a decreased salpingostomy success rate.     

Risk factors for conversion to laparotomy during laparoscopic management of an ectopic pregnancy

Objective: To identify risk factors for conversion to laparotomy during laparoscopic management of ectopic pregnancy. Methods: A retrospective chart review of patients who underwent laparoscopy for treatment of ectopic pregnancy, during a 32-month period (6/1999–2/2002), at the University of Miami Jackson Memorial Hospital. We identified 229 patients; 201 had a successful laparoscopy (non-converted group) and 28 who were converted to laparotomy (converted group).Variables analyzed between the two groups were demographic data, patient-related risk factors available to the surgeon prior to the surgery (previous laparotomy, previous laparoscopy, history of PID, history of endometriosis, diameter of ectopic pregnancy as measured by ultrasound, amount of free fluid on ultrasound, BMI), and surgeons’ experience. Results: Out of the 229 laparoscopies, 28 were converted to laparotomy (12.2%). The rate of conversion was significantly higher for less experienced compared to experienced surgeon (OR=6.1, 95% CI=2.35–15.88). Significantly more women had a BMI>30 kg/m² in the converted group compared to the non-converted group (42% vs. 14%; OR=4.28, 95% CI=1.7–10.75) and the converted group had significantly higher rate of large free fluid reported on ultrasound compared to the non-converted group (21.42% vs. 7.46%; OR =3.38, 95% CI=1.04–10.61). Conclusion: Less experienced surgeon, BMI>30 kg/m², and large amount of free fluid on ultrasound increase the risk of conversion to laparotomy during laparoscopic management of ectopic pregnancy.     

A systematic review and meta-analysis of lifestyle and body mass index predictors of successful assisted reproductive technologies

Objective: Lifestyle (smoking, drinking alcohol) and body mass index (BMI) predictors of successful outcomes in assisted reproductive technology (ART) treatments were examined in this meta-analysis.

Method: A bibliographic search was undertaken using six databases. The review was informed by PRISMA/MOOSE guidelines. Meta-analytic data were analysed using random effects models.

Results: We included 77 studies examining effects of BMI, smoking and drinking alcohol. Patients with a BMI<?=24.9 were significantly more likely to achieve LB/pregnancy than with BMI>?=25 OR?=?1.219 (95% CI:1.128–1.319, z?=?4.971, p?<?.001; I²?=?53.779%, p?=?.001). Non-smokers were significantly more likely to achieve a LB or pregnancy than smokers OR?=?1.457 (95% CI:1.228–1.727, z?=?4.324, p?<?.001; I²?=?51.883; p?=?.001). Meta-regression revealed the number of embryos transferred significantly moderated the effects of smoking on ART outcomes, and there was a trend indicating primary infertility and high BMI were also significant moderators. The evidence for drinking alcohol was inconclusive due to the small number of studies.

Conclusions: This meta-analysis confirms that ART treatment success can be predicted with lifestyle factors. Further, non-smokers’ relative odds of pregnancy/live birth increase as more embryos were transferred but there was a trend that the odds of pregnancy/live birth decrease with primary infertility and high BMI.     

Effect of Hysterectomy due to Benign Diseases on Female Sexual Function: A Systematic Review and Meta-analysis

ObjectiveDetermination of the effect of hysterectomy caused by benign diseases on female sexual function.Data SourcesA search was performed on Scopus, PubMed, Science Direct, ProQuest, ISI Web of Knowledge, and Embase databases. The keywords included hysterectomy (as exposure) and female sexual function (as outcome). Original English observational studies, including cohort, case-control, and cross-sectional studies published as of February 2021, which reported an association between any type of hysterectomy caused by benign female disease and sexual function as an outcome, were included in the study. Studies in participants who received hormone replacement therapy and had sex other than heterosexuals were not included. There was no limit to the initial search period, and articles published by February 2021 were searched.Methods of Study SelectionThe search process resulted in the retrieval of 5587 potentially related articles. After removing duplicated studies, the title and abstract were reviewed and 77 articles remained with the removal of unrelated items. The full text of 14 articles was published in non-English languages, and 52 articles were removed because they did not meet the inclusion criteria, and finally, 11 articles were included in the final analysis.Tabulation, Integration, and ResultsThe Newcastle-Ottawa scale was used to assess the methodological quality of included studies. The evidence was synthesized using meta-analysis via random-effect model with the Der Simonian and Laird weighted method. Publication bias was assessed using the funnel plot and Begg's and Egger's tests. The pooled standardized mean difference for sexual function in hysterectomy vs nonhysterectomy group was 0.08 (95% confidence interval, ?0.38 to 0.55; I² = 96.8%; χ² = 307.94; p <.001; τ² = 0.59). Publication bias and small study effects were not detected. The results of the subgroup analysis showed that the possible sources of heterogeneity are the World Bank countries classification and type of hysterectomy (in some studies, the type of hysterectomy was not specified separately for the study groups; because of this, comparisons were made between Total and supracervical/total). Pooled standardized mean difference was affected by the type of sexual function scale, World Bank countries classification, type of hysterectomy, ovary status, and reproductive status. The results of meta-regression analysis also showed that for each month of distance from hysterectomy, women's sexual function score increases by 0.18.ConclusionThe results of this study showed that hysterectomy caused by benign diseases does not change the sexual function significantly.     

Early prediction of the success of methotrexate treatment success by 24–hour pretreatment increment in HCG and day 1–4 change in HCG

Research questionSeveral studies have tried to identify early markers of treatment outcome after methotrexate (MTX) treatment for ectopic pregnancy, including pretreatment and day 4 human chorionic gonadotrophin (HCG) concentrations and their corresponding changes, and the increment in HCG during the initial 24 h after treatment. There have, however, been conflicting results. This study aimed to re-evaluate the role of these markers in the earlier identification of treatment success in a large cohort of women.DesignThis was a retrospective cohort study including women diagnosed with an ectopic pregnancy and treated with a regimen of a single dose of MTX. A comparison of maternal and gestation characteristics was made between groups in whom treatment was successful or failed.ResultsA total of 292 women treated with single-dose intramuscular MTX for ectopic pregnancy were included in this study. In the overall cohort, the treatment success rate with a single dose of MTX was 62.7% (183/292). Only two independent determinants were significantly associated with treatment success: the initial 24-h percentage increase in HCG (adjusted odds ratio [OR] 1.82, 95% confidence interval [CI] 1.26–2.63; P < 0.001) and the percentage change in HCG from day 1 to day 4 (adjusted OR 1.12, 95% CI 1.04–1.21; P < 0.001). The optimal cut-off points for prediction of treatment success were an increment of less than 17% in the 24 h before treatment and a decrease of more than 22% between the day 1 and day 4 HCG concentrations.ConclusionsA small increase in HCG concentration 24 h before treatment with MTX, alongside a decline in HCG concentration from day 1 to day 4, may predict the success of medical treatment for an ectopic pregnancy.     

Variation of Laparoscopic Ovarian Drilling for Clomiphene Citrate-resistant Patients with Polycystic Ovary Syndrome and Infertility: A Meta-analysis

ObjectiveTo evaluate novel surgical variations of laparoscopic ovarian drilling (LOD) and compare with standard bilateral LOD.Data SourcesElectronic databases were searched, including Cochrane database, CENTRAL, Ovid MEDLINE, Embase, PsycINFO, PubMed, Virtual Health Library, OpenSIGLE, ClinicalTrials.gov, ISRCTN, and The Chinese Clinical Trial Register in February 2019.Methods of Study SelectionRandomized controlled trials (RCTs) evaluating LOD for patients with clomiphene citrate-resistant polycystic ovary syndrome and infertility and reporting reproductive outcomes, surgical complications, serum indexes, menses resumption, and ultrasound results were included. Quality and risk of bias were evaluated by 2 authors, respectively.Tabulation, Integration, and ResultsA total of 20 RCTs with 1615 patients were included. Evaluation of the quality of evidence for each study was based on each study's limitations of 5 outcome domains described by the Grading of Recommendations, Assessment, Development, and Evaluation and found to be moderate to very low. Live births were only reported by 4 studies. Unilateral LOD did not differ with bilateral LOD in reproductive outcomes, such as pregnancy (p = .11, I² = 75%), ovulation (p = .08, I² = 0%), miscarriage (p = .61), and menstruation resumption (p = .06). There was insufficient evidence regarding efficacy and safety of novel methods of LOD, such as transvaginal hydrolaparoscopy (1 RCT) and micro-LOD (3 RCTs). Evidence regarding the suitable number of ovarian punctures, duration of drilling, and antimüllerian hormone or antral follicle numbers following LOD were inconclusive.ConclusionUnilateral LOD seems to be suitable replacement for conventional bilateral LOD for clomiphene citrate-resistant polycystic ovary syndrome, although more studies involving long-term reproductive efficacy, adverse events, and varying forms of LOD are warranted.