Photocoagulation of early pelvic endometriosis with the Nd: YAG laser through the laparoscope

Our prospective study evaluated the efficacy of the Nd:YAG laser (MMB-AT MediLas 2) for early-stage clinical endometriosis. Patients with suspected endometriosis underwent diagnostic laparoscopy, and if mild or moderate pelvic endometriosis was discovered, the lesions were treated with the Nd:YAG laser at a power setting of 20 w with intermittent, one- to three-second exposures. All the patients are being treated postoperatively with danazol (800 mg/day) for three to nine months. At this writing, 14 of 24 patients selected for laparoscopy were eligible for treatment with the Nd:YAG laser. Six weeks after treatment all the patients reported relief of their initial symptoms. To date, two patients have had repeat laparoscopy after Nd:YAG photocoagulation of mild endometriotic lesions. Neither patient had evidence of disease at the second laparoscopy.     

YAG laser contact therapy of ovarian endometriosis under laparoscopy]

Thirty-six patients with ovarian endometriosis were treated with Nd:YAG laser contact irradiation under laparoscopic control. Indications for laparoscopy were infertility (n = 20) and dysmenorrhea (n = 16). The laparoscopic procedures so far undertaken in our clinic include: Aspiration of chocolate cyst, removal of ovarian endometriosis, adhesion-lysis, uterine nerve ablation, coagulation of peritoneal endometriosis and irrigation. No complications were seen. After undergoing this procedure, eight of 20 patients achieved pregnancy and 15 of 16 patients obtained pain relief. Serum CA125 levels were significantly decreased postoperatively. We confirmed that contact irradiation with a cone-shaped sapphire probe provides adequate incision and lysis at lower power levels, and that this method is an effective treatment for ovarian endometriosis.     

Prostaglandins in peritoneal fluid of women with minimal and mild endometriosis]

Peritoneal fluid from 52 women with minimal and mild endometriosis was aspirated at laparoscopy and PGs were analyzed. Peritoneal lesions were classified into black, red and white lesions and peritoneal pockets, and were excised and pathological examination performed. Patients were classified into the black lesion group (n = 17) and the red lesion group (n = 35) according to the main colour of the lesions. 1. Endometrial gland and stroma were found in 78% of black lesions, 53% of red lesions, 60% of white lesions and 62% of peritoneal pockets. Infiltration of lymphocytes was found in 74% of black lesions, 83% of red lesions, 80% of white lesions and 77% of peritoneal pockets. 2. The fluid volume of the red lesions group was significantly higher than that of the control group (p less than 0.01). But the fluid volume of the black lesions group was insignificant as compared with that of the control group. 3. The PGE2 and PGF2 alpha concentrations in fluid from the red lesion group were significantly higher than not only the control group (p less than 0.001, p less than 0.05) but also the black lesion group (p less than 0.01, p less than 0.05). Only the PGE2 concentration in fluid from the black lesion group was significantly higher than that of the control group (p less than 0.001). 4. In the red lesion group which had no infertility factors without endometriosis, 20 of 25 patients achieved pregnancy (80%) in a one-year follow up. This was significantly higher than in the black lesions group (44%).(ABSTRACT TRUNCATED AT 250 WORDS)     

The concentration of 13,14-dihydro-15-keto prostaglandin F2 alpha and prostaglandin E2 in peritoneal fluid of infertile patients with and without endometriosis

Prostaglandin F2 alpha (PGF2 alpha) metabolite (13,14-dihydro-15-keto PGF2 alpha) and prostaglandin E2 (PGE2) were assayed in the cul-de-sac fluid aspirated from 15 patients with endometriosis, in saline peritoneal washings of 5 patients with unexplained infertility, and in 5 control subjects. The fluid from the cul-de-sac of patients with endometriosis showed wide variations in the concentrations of PGF2 alpha metabolite and PGE2. There was no correlation between the concentration of these prostaglandins (PGs) and the stage of the cycle. Saline peritoneal washings from patients with unexplained infertility had significantly higher concentrations of PGF2 alpha metabolite than the control subjects. The concentration of PGE2 in the saline peritoneal washings was higher in the group with unexplained infertility than in the control group; however, the difference was not significant. The concentration of PGF2 alpha metabolite and PGE2 in the peritoneal saline washings from patients with unexplained infertility were no different from the concentrations of these PGs in the peritoneal fluid (PF) from patients with endometriosis. PG concentration in PF of infertile patients with or without endometriosis is a new variable for evaluation in these patients.     

Nd:YAG laser therapy for infertility with a contact-type probe

Laparoscopic Nd:YAG laser surgery for tubal adhesiolysis, hydrosalpinx and other disorders is an effective treatment for female infertility that causes relatively little tissue damage. In initial studies using contact-type probes, the 0.4-mm-diameter probe and 10 mm/sec incision speed were found to cause less tissue degeneration than did other combinations (P less than .05). Fifteen infertile women were treated at laparoscopy with a Nd:YAG laser; one of six with hydrosalpinx achieved pregnancy after salpingostomy using a contact-type probe, two of three with tubal adhesions achieved pregnancy after adhesiolysis with the Nd:YAG laser, and three of six with polycystic ovaries achieved pregnancy after wedge resection using a contact-type probe. Five of fifteen infertile women conceived after Nd:YAG laser surgery with a contact-type probe under laparoscopy. We confirmed that contact irradiation with a ceramic incising probe is capable of creating an adequate incision at low power levels and that laparoscopic Nd:YAG laser surgery for infertile women is an effective treatment.     

Peritoneal fluid concentrations of interleukin-17 correlate with the severity of endometriosis and infertility of this disorder

This prospective study aimed to determine whether patients with endometriosis are having different level of interlukin-17 (IL-17) in peritoneal fluid when compared with patients without endometriosis. The patients with minimal/mild endometriosis had a significantly higher level of IL-17 in peritoneal fluid compared with those with moderate/severe endometriosis or without endometriosis. The concentration of IL-17 in peritoneal fluid was significantly higher when endometriosis and infertility coexist. However, the concentration of IL-17 in peritoneal fluid did not correlate with the phase of the menstrual cycle in the patients with or without endometriosis. Our study suggested that IL-17 might play an important role in the pathogenesis of early endometriosis and endometriosis-associated infertility.     

Cytokine profiles in serum and peritoneal fluid from infertile women with and without endometriosis

OBJECTIVE: To study the serum and peritoneal fluid cytokine profiles in infertile women with minimal/mild active endometriosis. METHODS: Fifty-seven consecutive infertile women undergoing laparoscopy for unexplained infertility had peritoneal fluid and serum samples obtained at the time of laparoscopy. The levels of interleukin-6 (IL-6), interleukin-8 (IL-8), interleukin-1 beta (IL-1 beta), vascular endothelial growth factor (VEGF), tumor necrosis factor-alpha (TNF-alpha), monocyte chemotatic protein-1 (MCP-1), RANTES, platelet derived growth factor (PDGF), soluble Fas (sFas), and soluble Fas Ligand (sFasL) in peritoneal fluid and serum were measured to compare the concentration in both biological fluids, in women who have minimal/mild red endometriosis using women with no endometriosis as controls. RESULTS: Peritoneal fluid levels of MCP-1, IL-8 and IL-6 were significantly higher in the endometriosis group (P < 0.012, P = 0.003, and P = 0.015, respectively). There was no significant difference in the peritoneal fluid levels of IL-1 beta, TNF-alpha, RANTES, VEGF, PDGF, sFas and sFasL in the two groups. Although serum levels of IL-8 were higher in women with endometriosis, the difference was not significant (P = 0.07). Serum levels of PDGF, IL-6, RANTES, IL-1 beta, TNF-alpha, and sFas, were not significantly different in the two groups. CONCLUSION: The elevated levels of MCP-1, IL-6, and IL-8 in peritoneal fluid but not serum may indicate the importance of local macrophage activating factors in the pathogenesis of endometriosis.     

Cellular components in peritoneal fluid in infertile patients with and without endometriosis

Cellular components in peritoneal fluid of infertile patients with and without endometriosis were evaluated in 102 patients with Wright's-Giemsa and Papanicolaou stains. The secretory activity of these cells was studied indirectly by assaying acid phosphatase, prostaglandin (PG) F2 alpha and PGE2 and complement components C3c and C4. The results showed that macrophages and lymphocytes were the dominant cells in peritoneal fluid of these patients. These cells were significantly increased in endometriosis patients, as compared with control subjects. In addition, peritoneal fluid acid phosphatase, PGF2 alpha and PGE2, and complement components C3c and C4 were significantly increased in patients with endometriosis. These cellular changes and their activation in peritoneal fluid may explain infertility associated with endometriosis.     

Glutathione peroxidase concentration in the peritoneal fluid from infertile women

OBJECTIVES: To assess the concentration of Plasma Glutathione Peroxidase (plGPx) in the peritoneal fluid (PF) of patients with unexplained infertility and infertile women with minimal and mild endometriosis. MATERIALS AND METHODS: 33 women were studied, including 8 infertile women with minimal or mild endometriosis, 15 patients with unexplained infertility and 10 patients with tubal occlusion (a reference group). Concentration of plGPx was measured in the PF using a commercially available ELISA kit (Oxis Inc.). RESULTS: The plGPx concentration was significantly (p = 0.04) lower in PF from women with unexplained infertility (846 +/- 177 ng/ml) compared to the reference group (1023 +/- 238 ng/ml), but did not differ significantly (p = 0.25) between women with endometriosis (918 +/- 81 ng/ml) and patients with tubal infertility. CONCLUSIONS: Our results suggest that low peritoneal plGPx concentration may play a role in the pathogenesis of infertility.     

Peritoneal fluid volume, estrogen, progesterone, prostaglandin, and epidermal growth factor concentrations in patients with and without endometriosis

Elevated prostaglandin (PG) levels in peritoneal fluid have been implicated as playing a role in infertility associated with endometriosis. This study was designed to measure peritoneal fluid levels of PG and other hormones that may influence PG release. Specific hormones measured included PGF2 alpha, PGE2, TxB2, 6-keto-PGF1 alpha, estrogen, progesterone, and epidermal growth factor. Peritoneal fluid volume and levels of estrogen, progesterone, and epidermal growth factor were significantly (P less than .05) increased during the secretory, as opposed to the proliferative, phase in both groups of patients, but no significant differences in these parameters were found between patients with and without endometriosis during either the proliferative or secretory phases. Although PG levels did not vary during the menstrual cycle in either group of patients, all four prostanoids were present in significantly (P less than .05) higher concentrations in patients with endometriosis as compared with patients without endometriosis. Furthermore, increased PG levels in patients with endometriosis appear to be due primarily to an increase in PG levels during the secretory phase of the cycle.     

Nd:YAG laser laparoscopy for ovarian endometriomas

Thirty patients with ovarian endometriomas were treated with Nd:YAG laser contact irradiation via laparoscopy. The indications for laparoscopy were infertility (16) and dysmenorrhea (14). The laparoscopic procedures undertaken so far at our clinic were aspiration of chocolate cysts, removal of ovarian endometriomas, adnexal adhesiolysis, uterine nerve ablation, coagulation of peritoneal endometriosis and irrigation. No complications occurred. After undergoing this procedure, 6 of 16 patients achieved pregnancy, and 13 of 14 obtained pain relief. The serum CA-125 levels were significantly decreased postoperatively. We confirmed that contact irradiation with a cone-shaped sapphire probe provides an adequate incision and lysis at low power levels and that this method is an effective treatment for ovarian endometriomas.     

A comparison of peritoneal fluid parameters of infertile patients and the subsequent occurrence of pregnancy

The effects of peritoneal fluid or its cellular components on human oocyte fertilization and cleavage cannot be studied directly. This report explores the association of laparoscopically obtained peritoneal fluid volume, macrophage count, and concentration of 124 infertility patients and their first occurrence of pregnancy during a 2-year follow-up period. Endometriosis patients who achieved pregnancy had a significantly lower mean fluid volume than those remaining nonpregnant. In patients with endometriosis, a fluid volume significantly less than the mean for all endometriosis patients carries a significantly greater chance of pregnancy. The time required for the occurrence of pregnancy in patients with endometriosis appears influenced by peritoneal fluid volume. Peritoneal fluid of patients with endometriosis, via an as yet unknown mechanism or substance, appears to be associated with reduced fertility.     

Treatment of endometriosis with a Nd:YAG tissue-contact laser probe via laparoscopy

The neodymium:yttrium-aluminum garnet (Nd:YAG) laser was used via laparoscopy in 84 patients complaining of infertility and/or pelvic pain. All patients in the study had biopsy-proven or visually confirmed pelvic endometriosis. The Nd:YAG laser was used in conjunction with sapphire probes as a touch technique on tissue. Problems usually encountered, such as mirror alignment, beam focus, and smoke plume, with carbon dioxide laser systems were avoided, and use of the laser in a liquid environment was possible. Restoration of fertility was seen in 39.7% with short follow-up; pain relief was excellent, especially in conjunction with uterosacral denervation.     

The present and future application of lasers to the treatment of endometriosis and infertility

Conventional approaches to the treatment of endometriosis usually require major surgery, prolonged use of medications or both. The laser has provided an opportunity to treat mild and moderate endometriosis at the time of diagnosis at laparoscopy, thus avoiding delays in attempts to conceive. This review describes the current use of the CO2, argon and Nd:YAG lasers in the treatment of endometriosis. Potential and future uses of the free-electron laser (FEL) are also described.     

Simultaneous laparoscopy for endometriotic women undergoing in vitro fertilization

ObjectiveThe aim of this study was to investigate simultaneous laparoscopy in endometriotic women with infertility undergoing in vitro fertilization (IVF).Materials and MethodsForty-seven infertile patients with endometriosis were enrolled in this retrospective study and underwent IVF cycles in a university affiliated hospital.ResultsThe chemical pregnancy, clinical pregnancy and live birth rates were statistically significantly different between patients with minimal or mild stage endometriosis and patients with moderate or severe stage endometriosis, who received simultaneous laparoscopy and modified IVF with a GnRH antagonist protocol. A higher live birth rate was achieved in IVF patients with minimal or mild stage endometriosis combined with laparoscopic treatment, than in patients who received traditional IVF with prior laparoscopic surgery for endometrioma.ConclusionSimultaneous laparoscopy combined with a modified IVF (GnRH antagonist) protocol may benefit patients with minimal and mild endometriosis. Traditional GnRH agonist IVF cycles may improve the fecundity rates in women with moderate and severe endometriosis after laparoscopic treatment.     

Peritoneal fluid volume and sex steroids in the preovulatory period in mild endometriosis

Summary. Twenty infertile women with laparoscopically confirmed mild endometriosis and ten women with tubal infertility underwent diagnostic laparoscopy 32 h after the onset of the endogenous luteinizing hormone (LH) surge during a spontaneous menstrual cycle. All visible peritoneal fluid was aspirated for assessment of volume and sex steroid content. There was no significant difference in peritoneal fluid volume or concentrations of oestradiol, progesterone and androstenedione between the two groups. Furthermore in the endometriosis group there was no significant difference in peritoneal fluid volume and concentrations of sex steroids between those women who had been treated previously with danazol and those who were left untreated.     

Peritoneal fluid volume and sex steroids in the pre-ovulatory period in mild endometriosis

Twenty infertile women with laparoscopically confirmed mild endometriosis and ten women with tubal infertility underwent diagnostic laparoscopy 32 h after the onset of the endogenous luteinizing hormone (LH) surge during a spontaneous menstrual cycle. All visible peritoneal fluid was aspirated for assessment of volume and sex steroid content. There was no significant difference in peritoneal fluid volume or concentrations of oestradiol, progesterone and androstenedione between the two groups. Furthermore, in the endometriosis group there was no significant difference in peritoneal fluid volume and concentrations of sex steroids between those women who had been treated previously with danazol and those who were left untreated.     

Total antioxidant status of peritoneal fluid in infertile women

OBJECTIVE: To determine whether impairment of the antioxidant systems of peritoneal fluid might be a factor responsible for infertility. STUDY DESIGN: Total antioxidant status was measured in peritoneal fluid obtained from 18 infertile women suffering from minimal or mild endometriosis, 23 patients with unexplained infertility, 12 women with tubal infertility and 13 fertile women. RESULTS: Total antioxidant status was significantly lower in peritoneal fluid from women with unexplained infertility (0.49+/-0.21 mmol/l) compared to both fertile patients (0.67+/-0.24 mmol/l, P=0.02) and women with tubal infertility (0.76+/-0.26 mmol/l, P=0.001). Peritoneal fluid total antioxidant status did not differ significantly between patients with endometriosis (0.61+/-0.2 mmol/l), tubal infertility and the fertile group (P>0.05). CONCLUSIONS: Our results suggest that low antioxidant status in peritoneal fluid may play a role in the pathogenesis of infertility.     

Fecundity of Infertile Women with Minimal or Mild Endometriosis And Women with Unexplained Infertility

Objective: To assess whether infertile women with minimal or mild endometriosis have lower fecundity than women with unexplained infertility.

Design: Prospective cohort study.

Setting: Twenty-three infertility clinics across Canada.

Patient(s): Three hundred thirty-one infertile women aged 20–39 years.

Intervention(s): Diagnostic laparoscopy for infertility. Infertile women with minimal or mild endometriosis (n = 168) were compared with women with unexplained infertility (n = 263). Both groups were managed expectantly. The women were followed up for 36 weeks after the laparoscopy or, for those who became pregnant, for up to 20 weeks of the pregnancy.

Main Outcome Measure(s): Fecundity refers to the probability of becoming pregnant in the first 36 weeks after laparoscopy and carrying the pregnancy for ≥20 weeks. The fecundity rate is the number of pregnancies per 100 person-months.

Result(s): Fecundity was 18.2% in infertile women with minimal or mild endometriosis and 23.7% in women without endometriosis (log-rank test). The fecundity rate was 2.52 per 100 person-months in women with endometriosis and 3.48 per 100 person-months in women with unexplained infertility. The crude and adjusted fecundity rate ratios were 0.72 and 0.83 (95% confidence interval = 0.53–1.32), respectively.

Conclusion(s): The fecundity of infertile women with minimal or mild endometriosis is not significantly lower than that of women with unexplained infertility.     

Rapid peptidomic profiling of peritoneal fluid by MALDI-TOF mass spectrometry for the identification of biomarkers of endometriosis

Peptidomic profiling of peritoneal fluid by Matrix Assisted Laser Desorption Ionization–Time of Flight Mass Spectrometry (MALDI-TOF-MS) may represent a promising, suitable, rapid method for early diagnosis and staging of endometriosis. In a case-control study, peritoneal fluid was collected from 23 patients affected by endometriosis (eight minimal/mild endometriosis and 15 moderate/severe endometriosis) and six “endometriosis free” women undergoing laparoscopy. MALDI-TOF mass spectra of the peptide fraction extracted from peritoneal fluid samples lead to identify biomarkers potentially suitable for discriminating between peritoneal fluid samples from women affected by minimal/mild endometriosis and those from women affected by moderate/severe endometriosis. Peptidomic analysis of peritoneal fluid samples may define putative peptide biomarkers suitable for staging endometriosis and improve our understanding of the pathogenesis of endometriosis.