Laser laparoscopy versus laparotomy in the treatment of infertility patients with severe endometriosis

The best pregnancy rates reported in the literature for infertility patients with severe pelvic endometriosis (stage IV) have been attributed to surgical management. In the last few years, improved endoscopic instruments have allowed gynecologists to treat difficult conditions with the CO 2 laser via laparoscopy, with good results. To assess the usefulness of the CO 2 laser via laparoscopy in treating severe pelvic endometriosis, two groups of patients were studied. Thirteen patients were treated by laparotomy (group I) and 11 patients by laparoscopy (group II). Seven achieved pregnancy in group I (53.8%), and pregnancy occurred in 6 patients in group II (54.5%). This study suggests that the management of severe pelvic endometriosis in infertility patients via laparoscopy seems to yield similar pregnancy rates to those treated with laparotomy, with the advantages of faster recovery and fewer hospitalization days for those undergoing laparoscopic surgery.     

Minimal and mild endometriosis. Nd:YAG laser treatment and changes in prostaglandin concentrations in peritoneal fluid

Among many patients, infertility originates with minimal and mild endometriosis. Recently, peritoneal fluid factors have come to be associated with infertility in minimal and mild endometriosis patients, and prostaglandin (PG) is suspected of being one of those factors. We use the Nd:YAG laser for treatment of endometriosis; a total of 52 cases of minimal and mild endometriosis have been treated so far with the laser under laparoscopy in our clinic. At the same time we measured the peritoneal fluid volume and PG concentration in peritoneal fluid. Peritoneal fluid volume and PGE2 concentrations were found to be significantly higher than those in the control group (tubal obstruction patients). Seven of 52 patients received second-look laparoscopy three months after Nd:YAG laser treatment; the PG concentration showed a tendency to decrease in many patients, and the PGE2 concentration turned out to be insignificant. Within one year, 30 patients achieved pregnancy. In minimal and mild endometriosis patients Nd:YAG laser treatment may alter the PG concentration in peritoneal fluid, thereby increasing the change of pregnancy.     

应用腹腔镜诊断和治疗子宫内膜异位症及不孕症的疗效

目的观察应用腹腔镜诊断和治疗盆腔子宫内膜异位症(内异症)及不孕症的疗效.方法对 314例经腹腔镜诊断为盆腔内异症的患者,按1985年美国生育学会修订的内异症分期标准(r-AFS)进行分期,其中Ⅰ期58例,Ⅱ期173例,Ⅲ期68例,Ⅳ期15例;并于腹腔镜下进行卵巢异位内膜病灶切除和粘连分解、盆腔腹膜异位内膜病灶内凝固术及清除腹腔液等手术治疗.术后随访36周,对妊娠者随访到妊娠20周.比较不同r-AFS分期患者术后累计妊娠率和流产率.结果 314例患者术后36周内妊娠共254例,分别为Ⅰ期50例(86.2%,50/58),Ⅱ期141例(81.5%,141/173),Ⅲ期52例(76.5%,52/68)和Ⅳ期11例(73.3%,11/15).经统计学检验,各期患者累计妊娠率比较,差异无统计学意义(P>0.05);术后24周内的妊娠率(93.7%,238/254)高于术后25～36周(6.3%,16/254;P<0.01).254例妊娠患者中,流产12例,流产率与分期无关(P>0.05);妊娠12周内流产率(83.3%,10/12)高于妊娠12周后(16.7%,2/12; P<0.05).结论应用腹腔镜可检查、诊断各期内异症及其引起不孕症的盆腔因素;腹腔镜手术治疗可提高内异症患者的妊娠率.在腹腔镜下清除腹腔液及进行腹腔异位内膜病灶内凝固术,可较完全地破坏盆腔腹膜异位内膜病灶,对各期特别是Ⅰ、Ⅱ期内异症患者生育力的恢复,有重要作用.     

Peritoneal recovery of motile and nonmotile sperm in the presence of endometriosis

It has been postulated that pelvic endometriosis may cause infertility by interfering with sperm motility and transport and even by increased intraperitoneal phagocytosis. The rate of sperm recovery at the time of laparoscopy performed in the immediate preovulatory period was determined in 29 patients (27.4%) with endometriosis (AFS stage I) and in 77 patients (72.6%) without endometriosis. The number of patients with motile sperm in both groups was similar (difference P greater than 0.30). It is concluded that mild endometriosis does not affect sperm transport and survival and that increased sperm phagocytosis in vivo is unlikely.     

Mild and moderate endometriosis. Comparison of treatment modalities for infertile couples.

A series of 1,268 consecutive patients with stage I and II endometriosis (American Fertility Society classification) were treated for the disease. In 675, no other factors contributed to their infertility. Among these patients, with no problems other than mild endometriosis, 57% (16/28) became pregnant when treated expectantly, 54% (51/95) after being treated medically, 47% (9/19) after laparoscopic cautery treatment, 81% (147/181) after laparoscopic laser treatment and 84% (97/116) after conservative surgery (laparotomy). Statistical analysis of the pregnancy rates revealed no difference between expectant, medical and laparoscopic cautery treatment. No difference was noted between laparotomy and laser laparoscopy; however, there was a statistically significant difference between these treatments and expectant, medical and cautery treatment. Similar results were seen with stage II endometriosis in couples with no contributing factors other than endometriosis: 39% of patients (23/59) became pregnant after medical treatment, 70% (80/115) after laser laparoscopy and 74% (46/62) after undergoing major conservative treatment (laparotomy). A statistically significant difference between medical treatment and laparotomy as well as laser laparoscopy was noted. However, no such difference existed between laparotomy and laser laparoscopy. Therefore, it appears that in experienced hands the use of laser laparoscopy in stage I and II endometriosis is as successful as major surgery and statistically significantly better than expectant, medical and laparoscopic cautery treatment.     

Symptom distribution among infertile and fertile endometriosis cases with different stages and localisations

OBJECTIVE: To evaluate endometriosis patients' symptoms and relate them to different stages and locations of endometriosis and also to fertility/infertility of the patients. STUDY DESIGN: Sixty-eight patients diagnosed with endometriosis constituted the population investigated in this cross-sectional observational study, 55 and 13 of whom were diagnosed from the visual findings recorded during laparoscopy and laparotomy, respectively. All cases were categorised as early- (stages I and II) or late (stages III and IV)-stage endometriosis and as fertile or infertile endometriosis. The extent of endometriosis was further divided into peritoneal, ovarian, and ovarian and peritoneal. Symptoms of dysmenorrhoea, deep dyspareunia, dyschesia and dysuria and also depressive mood state were analysed and compared among those different groups. RESULTS: Cyclic chronic pelvic pain was more relevant in late-stage endometriosis (P = 0.04). Deep dyspareunia, painful defecation, dysuria, infertility, and depressive state did not differ with stages of endometriosis or fertility status. Admission for pelvic pain of any duration was more prevalent among fertile patients with endometriosis (P = 0.008). Chronic noncyclic pelvic pain was more frequently observed in patients with fertile than in those with infertile endometriosis (P = 0.01). More cases in the fertile group experienced noncyclic pelvic pain (P = 0.04). More patients admitted with cyclic pelvic pain had ovarian or ovarian and peritoneal endometriosis than peritoneal endometriosis only (P = 0.03). Infertility was more prevalent among peritoneal endometriosis cases than among those with ovarian or peritoneal and ovarian involvement (P = 0.008). CONCLUSION: Symptoms of endometriosis may predict the stage and localisation of the disease to some extent.     

Laparoscopic cautery in the treatment of endometriosis-related infertility

Life table analysis and the two-parameter exponential method have been applied to pregnancy rates in 72 patients undergoing laparoscopic cautery exclusively. Patients with male factor infertility were excluded. Estimated cure rates for patients with stage I and II disease were 98.2% and 76.6%, respectively (not significantly different). No significant difference was seen when anovulation complicated the endometriosis (68.6%). When greater than one infertility factor was present, a significant difference was observed (50.6%). Patients with stage I disease had an average fecundity of 10.30% with decreasing values observed in stage II (7.59%), anovulation (6.67%), and more than one infertility factor (3.33%). We conclude that laparoscopic cauterization is an effective mode of therapy for the treatment of stage I and II endometriosis associated with infertility.     

Temporary ovarian suspension at laparoscopy for prevention of adhesions

We performed an innovative technique of temporary ovarian suspension after operative laparoscopy for stage 3 and 4 endometriosis and evaluated the results in a retrospective study. Subjects were 20 women who underwent operative laparoscopy for infertility. Temporary ovarian suspension to the anterior abdominal wall was performed as the last step in the surgical procedure. It was done in an attempt to separate adhesiogenic surfaces during the initial phase of tissue healing (5-7 days). No complications occurred. After excluding patients who had additional infertility factors and/or were of advanced reproductive age, nine women tried to conceive spontaneously. Of these, five conceived (55%): three delivered, one pregnancy continues (80%), and one woman had an ectopic pregnancy (20%). Of the remaining 15 patients who failed to conceive spontaneously, 5 had a second-look laparoscopy. In four patients (80%), we found no evidence of recurrent adhesions. The remaining 20% had minimal adhesions. Temporary ovarian suspension appears to be simple and safe, and may be effective in preventing postoperative adhesions near the ovaries after operative laparoscopy for advanced endometriosis.     

The effect of laparoscopic ablation or danocrine on pregnancy rates in patients with stage I or II endometriosis undergoing donor insemination.

The effect of treatment on stages I and II endometriosis was evaluated in 61 women with laparoscopically proven disease who were undergoing therapeutic donor insemination. Only treatment cycles completed after diagnostic laparoscopy were used for analysis. To evaluate fecundity, we performed life-table analysis on 343 treatment cycles of therapeutic donor insemination in 67 patients with stage I or II endometriosis and compared it with 212 cycles in 43 patients with no female infertility factors. Average monthly fecundity and cumulative conception rates over six cycles were calculated for each group. A significant difference was found when patients with laparoscopically proven normal anatomy were compared with those with endometriosis (P = .002). The fecundity did not differ significantly between stage I and stage II endometriosis (P greater than .05). Neither ablation during laparoscopy nor medical treatment with danocrine improved the fecundity of patients with early-stage endometriosis (P greater than .05).     

Evaluation of adhesion reformation by early second-look laparoscopy following microlaser ovarian wedge resection

Early second-look laparoscopy, done 6 to 12 weeks postoperatively, was utilized to evaluate recurrent adhesion formation following microlaser ovarian wedge resection. Forty-nine ovaries in 25 consecutive infertility patients undergoing microlaser surgery for deep ovarian endometriosis or polycystic ovarian disease, refractory to medical treatment, were evaluated from October 1981 through March 1983. All patients subsequently underwent a second-look nonlaser laparoscopy to evaluate the extent of healing and to bluntly lyse any subsequent adhesions with the Olympus laparoscope (Olympus Corporation, Lake Success, NY) second-puncture probe: 36.7% of the ovaries had recurring adhesions, 83.3% of these adhesions were mild and filmy and 16.7% were moderate and dense. Additionally, four ovaries were viewed approximately 1 year postoperatively, with two ovaries that previously had mild and filmy adhesions lysed at 6 weeks having no recurrent adhesions. The actual pregnancy rate in this study is 60%, with 15 of the 25 patients conceiving at least once and 2 patients conceiving twice. The majority of pregnancies occurred within the first 6 months postoperatively, with the longest initial pregnancy occurring 22 months postoperatively. Thus, microlaser ovarian surgery, coupled with early second-look laparoscopy, appears efficacious in minimizing adhesion reformation and seems to have little adverse effect on subsequent conception.     

A study of second-look laparoscopy after acute salpingitis

Acute salpingitis (AS) has a major impact on the reproductive health of women. In this study second-look laparoscopy was assessed for its ability to predict reproductive function after AS. We questioned 158 women who had had a second-look laparoscopy with tubal dye insufflation after laparoscopically proven AS between September 1984 and August 1989. The answers of 69 women with at least two years of involuntary infertility were analyzed. The mean follow-up period was 76 months (range 53–108 months). Second-look laparoscopy revealed bilateral tubal occlusion in 21.7% (15/69). Bilateral tubal occlusion was found in 9.5% (2/21) after mild stage, 20% (4/20) after moderate stage and 32.1% (9/28) after severe stage AS. The rate of infertility during follow-up was 9.5% (stage I), 35% (stage II) and 39.9% (stage III). Eighty per cent (12/15) of women with proven bilateral tubal occlusion after treated AS had involuntary infertility, and 14.8% (8/54; P=0.000001) of women with one or both tubes patent also had infertility. Specificity, sensitivity and positive predictive value for subsequent infertility were 85.2%, 80% and 84.1%, respectively. Pelvic adhesions (21/69) were strongly correlated with bilateral tubal occlusion (8/21; 38.1%; P=0.029), a history of chronic pelvic pain (14/21; 66.7%; P=0.00024), as well as failure to achieve an intrauterine pregnancy (10/21; 47.6%; P=0.024). Recurrent pelvic infections occurred in 16% (12/69) and ectopic pregnancies in 7.3% (5/69). Operations for infertility and pelvic pain (excluding ectopic pregnancy), were carried out in 11.6% (8/69). We conclude that second-look laparoscopy after treated AS have accurate evaluation of reproductive function. Received: 10 January 1996 / Accepted: 29 April 1996     

Collaborative study of pregnancy rates following danazol therapy of stage I endometriosis

Pregnancy rates following danazol therapy of endometriosis vary widely. In order to reduce variations in patient selection and establish danazol effectiveness, six collaborative centers evaluated 75 infertile patients with normal infertility screening studies and mild (stage I) endometriosis documented by laparoscopy. Following diagnosis and 3 months coital exposure, all patients were treated with danazol for 6 months, and patient surveillance after danazol therapy lasted at least 12 months, with a range of 12 to 34 months. Of the 75 patients treated, 21 (28%) conceived, and the term pregnancy rate was 20% (15 of 75). The low pregnancy rate observed in these patients suggests that the role of danazol therapy for patients with mild endometriosis and infertility should be reconsidered.     

Adhesion reformation after reproductive surgery by videolaseroscopy

After initial videolaseroscopy for the treatment of endometriosis-associated infertility, 157 patients underwent a second-look laparoscopy to evaluate and treat recurrence of disease and/or adhesions. The patients were divided into two groups. Group 1 consisted of 135 patients who underwent second-look laparoscopy for persistent infertility and/or recurrence of pain. Group 2 consisted of 22 patients who achieved pregnancy after initial surgery and underwent second-look laparoscopy for evaluation of ectopic pregnancy or in association with uterine evacuation for first trimester spontaneous abortion. Both groups of patients demonstrated a significant reduction in adhesion scores involving the ovaries, tubes, posterior cul-de-sac, anterior cul-de-sac, and omentum/bowel. Although the initial mean adhesion scores were similar for both groups, at second-look laparoscopy the mean adhesion scores were significantly lower for group 2, particularly for ovarian and tubal adhesions. None of the patients formed de novo adhesions. From these results we may conclude that videolaseroscopy: (1) is effective in reducing peritoneal adhesions; (2) is associated with a low frequency of postoperative adhesion recurrence; and (3) appears to completely avoid de novo adhesion formation.     

Reproductive outcome after laparoscopic treatment of minimal and mild endometriosis using Helica Thermal Coagulator

OBJECTIVE: To investigate the reproductive outcome following Helica Thermal Coagulator (Helica TC) in an infertile population with early-stage endometriosis. DESIGN: A clinical observational trial conducted in a NHS tertiary referral centre for treatment of endometriosis. Forty-four healthy infertile women (mean age 21 years, range 18-34 years) with laparoscopically confirmed diagnosis of minimal (stage I) or mild (stage II) endometriosis were included. All visible endometriotic lesions and adhesions were treated using Helica TC at the same time of diagnostic laparoscopy. Following laparoscopy, women attempted to conceive spontaneously and were followed for 12 months or until delivery. No hormonal therapy for endometriosis was given whatsoever. RESULTS: One woman was lost to follow-up and the remaining 43 women were considered in the final analysis. The cumulative pregnancy rate was 23.2% (10/43). All pregnancies occurred spontaneously and neither miscarriages nor ectopic pregnancies were observed. Pregnancy rate did not differ between women with stage I and those with stage II endometriosis. The time-to-pregnancy was similar in women with different stage endometriosis. No surgical complications were encountered. CONCLUSIONS: These findings suggest that Helica TC is a simple and safe conservative laparoscopic surgery for early-stage endometriosis. Helica TC appears to improve reproductive outcome in women with otherwise unexplained infertility. Large RCTs are needed to define these preliminary data.     

Effect of peritoneal fluid from endometriosis patients on sperm motion characteristics and acrosome reaction

OBJECTIVE: To determine whether peritoneal fluid from women with endometriosis contributes to infertility by impairing sperm motion and functional characteristics. METHODS: Women with endometriosis (n = 20) underwent laparoscopy for infertility or pelvic pain. Patients undergoing tubal ligation served as controls (n = 14). Peritoneal fluid was aspirated from women with endometriosis, or from women undergoing laparoscopic tubal ligation. Sperm motility, motion characteristics and acrosome reaction were assessed following incubation with peritoneal fluid. RESULTS: Sperm motility, motion characteristics, and acrosome reaction did not differ significantly between the two groups after 3, 5, or 24 hours of incubation with peritoneal fluid. CONCLUSIONS: Sperm motion or functional characteristics showed no significant impairment when sperm from normal donors were incubated with peritoneal fluid from patients with endometriosis. It is unlikely that peritoneal fluid in these patients contributes to infertility.     

Serum CA-125 levels in the diagnosis and management of endometriosis.

The value of CA-125 for the diagnosis and management of endometriosis (EN) was investigated by assaying the marker in the serum and peritoneal fluid (PF) from patients with the disease in comparison with control subjects. Of women who underwent 270 consecutive laparoscopies, 81 with various stages of EN (18 stage I, 13 stage II, 35 stage III and 15 stage IV) and 38 with normal pelvic findings were studied. CA-125 serum values increased progressively in relation to the severity of the disease. The levels in stages III and IV EN were significantly higher (P less than .01) than in stages I and II or control patients. The latter two groups did not differ from each other. High CA-125 PF values were found in all the patients investigated. Twenty-two patients with EN were treated with a gonadotropin releasing hormone agonist for six months before second-look laparoscopy or laparotomy. CA-125 values decreased significantly after one month of medical treatment and remained unchanged during the course of therapy. No significant relationship was found in the outcome after therapy.     

Endometriosis and subfertility: is the relationship resolved?

There are many arguments to support the hypothesis that there is a causal relationship between the presence of endometriosis and subfertility. These arguments are reviewed in this article and include: (1) an increased prevalence of endometriosis in subfertile women compared with women of proven fertility; (2) a reduced monthly fecundity rate (MFR) in baboons with mild to severe (spontaneous or induced) endometriosis compared with those with minimal endometriosis or a normal pelvis; (3) a trend toward a reduced MFR in infertile women with minimal to mild endometriosis compared with women with unexplained infertility; (4) a dose-effect relationship: a negative correlation between the r-AFS stage of endometriosis and the monthly fecundity rate and crude pregnancy rate; (5) a reduced monthly fecundity rate and cumulative pregnancy rate after donor sperm insemination in women with minimal-mild endometriosis compared with those with a normal pelvis; (6) a reduced MFR after husband sperm insemination in women with minimal to mild endometriosis compared with those with a normal pelvis; (7) a reduced implantation rate per embryo after IVF in women with moderate to severe endometriosis compared with women with a normal pelvis; and (8) an increased monthly fecundity rate and cumulative pregnancy rate after surgical removal of minimal to mild endometriosis.     

Diagnosis of stage I endometriosis: comparing visual inspection to histologic biopsy specimen

STUDY OBJECTIVE: To evaluate positive predictive value (PPV) of visual diagnosis at laparoscopy compared with biopsy findings according to severity of endometriosis. DESIGN: Retrospective study (Canadian Task Force classification II-2). SETTING: Academic referral center. PATIENTS: Women who underwent laparoscopic biopsies for suspected endometriosis. INTERVENTIONS: A total of 238 biopsy specimens (73 endometriomas and 165 peritoneal implants) were taken from 104 patients undergoing laparoscopy for evaluation of chronic pelvic pain thought to be caused by endometriosis. MEASUREMENTS AND MAIN RESULTS: Accuracy of laparoscopic findings compared with histology-proved endometriosis by severity of disease and location of endometriotic lesions. Overall PPV per patient was 86.5%, which was 75.8% for stage I disease compared with 89.7%, 100%, and 90.6%, respectively, for disease stages II to IV (p = .037). The PPV per biopsy specimen of stages I to IV endometriosis was 66.1%, 78.0%, 92.0%, and 81.1%, respectively (.049). When endometriomas and peritoneal biopsy specimens were analyzed separately, no difference in PPV existed (79% vs 77%; p = .67). CONCLUSION: High overall PPV existed in our study, especially in patients with advanced disease. The PPV per patient was higher than the PPV per biopsy specimen indicating that ability to diagnose endometriosis may be improved by performing multiple biopsies. This is particularly true in stage I where failure to confirm may be greatest.     

Laparoscopy for the treatment of unexplained infertility

Aim:  To determine the best treatment for unexplained infertility.
Methods:  A retrospective study was used to examine Japanese women with unexplained infertility that had undergone laparoscopy. The main outcome measure of the study was the rate of pregnancy after laparoscopy.
Results:  One hundred and thirty-eight women diagnosed with unexplained infertility received laparoscopy and as a result 55 women had their diagnosis of unexplained infertility confirmed. There were no statistically significant differences between the women who became pregnant after laparoscopy in terms of duration of infertility, duration of treatment or age. The pregnancy rate of women with unexplained infertility was 56.4%, with 90% of these pregnancies achieved within the first 6 months. There were 64 women with minor endometriosis considered to be suffering from unexplained infertility before laparoscopy. The characteristics of the patients in the unexplained infertility group and in the minor endometriosis group were similar, but patients with minor endometriosis were found to have a lower pregnancy rate compared to those with unexplained infertility (35.9% vs 56.4%; P  = 0.02).
Conclusions:  The effective period after laparoscopy appears to be 6 months. Assisted reproductive technology should be considered after that time. Pregnancy rates were low in women with minor endometriosis compared with unexplained infertility. It is important to clarify the cause of infertility using laparoscopy. (Reprod Med Biol 2006; 5 : 59–64)     

Women who are not exposed to spermatozoa and infertile women have similar rates of stage I endometriosis.

OBJECTIVE: To compare the prevalence of endometriosis and its different stages in infertile women and women not exposed to spermatozoa. DESIGN: Prospective study. SETTING: Artificial insemination donor program at a university hospital. PATIENT(S): One hundred fifty women unable to conceive because they had not been exposed to spermatozoa (134 with azoospermic partner, 10 with an HIV-positive partner, and 6 without a male partner). Controls were 750 women in infertile couples in which the male partner had normal sperm. INTERVENTION(S): Laparoscopy was systematically performed in a blinded manner in both groups as part of the infertility work-up. MAIN OUTCOME MEASURE(S): Diagnosis of endometriosis. RESULT(S): In unexposed women and controls, the prevalence of endometriosis was similar (32% and 34.5%). Rates of stage I disease were also similar in both groups (26% and 19.3%). There was a significant trend toward higher stages of endometriosis in infertile women (stage II disease, 3.3% vs. 5.7%; stage III disease, 1.3% vs. 3.1%; stage IV disease, 1.3% vs. 6.4%). Endometriosis was not associated with the few demographic characteristics that differed between groups. CONCLUSION(S): From an epidemiologic point of view, stage I endometriosis is not more common in infertile women than in unselected women. However, stage II to IV endometriosis was more frequent in infertile women. Whereas a relation between stage I endometriosis and infertility seems unlikely, the relation between stages II to IV endometriosis and infertility seems possible.