Gonadotropin-releasing hormone agonist treatment before abdominal myomectomy: a controlled trial

OBJECTIVE: To ascertain whether adjuvant gonadotropin-releasing hormone (GnRH) agonist therapy decreases blood loss during abdominal myomectomy. DESIGN: Randomized controlled trial. SETTING: Academic reproductive surgery center. PATIENT(S): One hundred premenopausal women requiring first-line conservative surgery for symptomatic intramural or subserous fibroids. INTERVENTION(S): Eight weeks of treatment with depot triptorelin before myomectomy or immediate surgery. MAIN OUTCOME MEASURES: Intraoperative blood loss, operating time, degree of difficulty of the procedure, and short-term rate of fibroid recurrence. RESULT(S): Mean (+/-SD) intraoperative blood loss was 265 +/- 181 mL in triptorelin recipients and 296 +/- 204 in patients who had immediate surgery (mean difference, -31 mL [95% CI, -108 to 46 mL]). No significant differences were observed in blood loss according to uterine volume, number of fibroids removed, or total length of myometrial incisions. Most procedures in either group were of routine difficulty. On ultrasonography 6 months after myomectomy, four women in the GnRH agonist group and one in the immediate surgery group had tumor recurrence. CONCLUSION(S): Treatment with a GnRH agonist before abdominal myomectomy has no significant effect on intraoperative blood loss. Thus, systematic use of medical therapy before abdominal myomectomy does not seem to be justified.     

Short-term postoperative GnRH analogue or danazol treatment after conservative surgery for stage III or IV endometriosis before ovarian stimulation: a prospective, randomized study

OBJECTIVE: To assess the effect of short-term use of a gonadotropin releasing hormone (GnRH) analogue for 3 months before ovarian stimulation in patients with stage III and IV endometriosis after conservative surgery. STUDY DESIGN: Eleven patients were randomly selected to receive intramuscular injections of GnRH analogue, leuprolide acetate (3.75 mg), every 28 days, or 400 mg danazol orally 2 times per day for 3 months before ovarian stimulation after conservative laparoscopic or laparotomy surgeryfor stage III and IV symptomatic endometriosis (group 1), as compared with 30 patients who had received no postoperative treatment with GnRH analogue or danazol but underwent ovarian stimulation immediately after thefirst menses within 3 months postoperatively (group 2). RESULTS: Although the number of oocytes retrieved and number of embryos per cycle were significantly higher in group 1, the pregnancy rate per cycle in group 1 was not significantly different from that in group 2 (18% vs. 20%). The cumulative pregnancy rate at 12 months was 54.5% and 56.7% in group 1 and group 2, respectively. With regard to recurrence of disease after 24 months of follow-up, group 2 had a statistically significantly higher recurrence rate (13.3%) than did group 1 (0%). CONCLUSION: Short-term use of GnRH analogue before ovarian stimulation in women with stage III or IV endometriosis confers no definite benefits on pregnancy rates per cycle when compared with patients who received ovarian stimulation within 3 months after conservative surgery.     

Surgical treatment of deep endometriosis and risk of recurrence

STUDY OBJECTIVE: To evaluate the risk of recurrence of deep endometriosis after conservative surgery. DESIGN: Retrospective analysis (Canadian Task Force classification II-3). SETTING: Tertiary care university hospital. PATIENTS: One hundred fifteen symptomatic patients operated on in our department from 1996 through 2002 with postoperative follow-up of at least 12 months. INTERVENTION: All patients underwent conservative surgery for deep infiltrating endometriosis. MEASUREMENT AND MAIN RESULTS: Risk factors for recurrence of symptoms and clinical findings and for repeated surgery were evaluated by univariate and multivariate analysis. During follow-up, we observed 28 patients with pain recurrence and 15 patients with recurrent clinical findings, and 12 patients required reoperation for deep endometriosis. Recurrence rates of pain and clinical findings during 36 months were 20.5% and 9%, respectively. Multivariate analysis showed that only age was a significant predictor of pain recurrence (OR 0.9, 95% CI 0.81-0.99, p<.05), enhancing the risk in younger patients. Recurrence of clinical signs of deep endometriosis was predicted by obliteration of the pouch of Douglas (OR 1.46, 95% CI 1.16-16.2, p<.05). Reoperation for deep endometriosis was predicted only by the incompleteness of first operation (OR 21.9, 95% CI 3.2-146.5, p<.001). CONCLUSION: Our study indicates that age, obliteration of the pouch of Douglas, and surgical completeness may have a significant influence on the recurrence of the disease.     

Laparoscopic uterosacral ligament resection for dysmenorrhea associated with endometriosis: results of a randomized,controlled trial

OBJECTIVE: To evaluate the efficacy of laparoscopic resection of the uterosacral ligaments in women with endometriosis and predominantly midline dysmenorrhea. DESIGN: Randomized controlled trial. SETTING: Two academic departments.One hundred eighty patients undergoing operative laparoscopy as first-line therapy for stage I to IV symptomatic endometriosis. INTERVENTION(S): Operative laparoscopy including uterosacral ligament resection or conservative surgery alone. MAIN OUTCOME MEASURE(S): Proportion of women with recurrence of moderate or severe dysmenorrhea 1 year after surgery. RESULT(S): No complications occurred. Among the patients who were evaluable 1 year after operative laparoscopy, 23 of 78 (29%) women who had uterosacral ligament resection and 21 of 78 (27%) women who had conservative surgery only reported recurrent dysmenorrhea. The corresponding numbers of patients at 3 years were 21 of 59 (36%) women and 18 of 57 (32%) women, respectively. Time to recurrence was similar in the two groups. Pain was substantially reduced, and patients in both groups experienced similar and significant improvements in health-related quality of life, psychiatric profile, and sexual satisfaction. Overall, 68 of 90 (75%) patients in the uterosacral ligament resection group and 67 of 90 (74%) patients in the conservative surgery group were satisfied at 1 year. CONCLUSION(S): Addition of uterosacral ligament resection to conservative laparoscopic surgery for endometriosis did not reduce the medium- or long-term frequency and severity of recurrence of dysmenorrhea.     

Recurrence of endometriosis in women with bilateral adnexectomy (with or without total hysterectomy) who received hormone replacement therapy

OBJECTIVE: To estimate the risk of recurrence after administration of hormone replacement therapy (HRT) among women who have had endometriosis and who underwent bilateral salpingo-oophorectomy (BSO). DESIGN: Prospective randomized trial (115 women receiving HRT and 57 not receiving HRT). SETTING; Public university hospital. PATIENT(S): Women with a histologic diagnosis of endometriosis in whom BSO was performed; 91.8% had a total hysterectomy. INTERVENTION(S): Periodical clinical examination, vaginal ultrasound, and CA-125 levels; surgical evaluation and histologic study. MAIN OUTCOME MEASURE(S): Recurrence rate, prognostic factors, and a mean follow-up time of 45 months. RESULT(S): There was no recurrence among women who did not receive HRT, versus a 3.5% rate (4 out of 115), or 0.9% per year, in women who received HRT. Two recurrences required abdominal surgery. There was one additional patient who required surgery, but the relationship to the endometriosis recurrence was controversial. Among women receiving HRT, the following risk factors were detected: peritoneal involvement > 3 cm (2.4% recurrence per year vs. 0.3%) and incomplete surgery (22.2% per patient vs. 1.9%). CONCLUSION(S): Patients with a history of endometriosis in whom total hysterectomy and bilateral salpingo-oophorectomy have been performed have a low risk of recurrence when HRT is administered. In those patients, HRT is a reasonable option. However, in cases with peritoneal involvement > 3 cm, the recurrence rate makes HRT a controversial option; if HRT is indicated, it should be monitored closely.     

A gonadotrophin-releasing hormone agonist compared with expectant management after conservative surgery for symptomatic endometriosis.

OBJECTIVE: To ascertain whether the frequency of pelvic pain recurrence is reduced and time to symptoms recurrence is prolonged in women with symptomatic endometriosis undergoing conservative surgery and post-operative hormonal therapy compared with women treated with surgery only. Pregnancy rates and time to conception in women wanting children were also evaluated. DESIGN: A multicentre, prospective, randomised controlled study. SETTING: Nineteen Italian academic departments and teaching hospitals specialising in reparative and reconstructive surgery. POPULATION: A total of 269 women undergoing conservative surgery for mild to severe symptomatic endometriosis. METHODS: After surgery the women were assigned to treatment with subcutaneous goserelin depot injections for six months or to expectant management. Dysmenorrhoea, deep dyspareunia, nonmenstrual pain and general discomfort were graded according to a verbal rating scale from 0 (absent) to 3 (severe) and the scores summed to give a total symptoms score. Only patients with at least one preoperative moderate or severe symptom were enrolled. The women were evaluated regularly for two years. MAIN OUTCOME MEASURES: Post-operative pain recurrences (total symptoms scores > or = 5), time to recurrence, pregnancy rates and time to conception in the two study groups. RESULTS: At one- and two-year follow up visits, 14/107 (13.1%) and 19/81 (23.5%) patients had moderate or severe symptoms recurrence in the goserelin group compared with, respectively, 22/103 (21.4%) and 27/74 (36.5%) in the expectant management group (P = 0.143 at 1 year and 0.082 at 2 years). Time to symptoms recurrence was significantly longer in the goserelin group according to survival analysis (Wilcoxon test, P = 0.041). Among women wanting children, few conceptions occurred in both the goserelin (8/69, 11.6%) and the expectant management group (14/76, 18.4%). There was no significant difference at survival analysis (Wilcoxon test, P = 0.427). CONCLUSION: Post-operative treatment with goserelin significantly prolonged the pain-free interval after conservative surgery for symptomatic endometriosis and did not influence reproductive prognosis.     

Gonadotropin-releasing hormone agonist inhibits estrone sulfatase expression of cystic endometriosis in the ovary

OBJECTIVE: To clarify the inhibitory effect of GnRH agonist on estrone (E(1)) sulfatase expression. DESIGN: Retrospective immunohistochemical study. SETTING: The Jikei University Hospital, Tokyo, Japan. PATIENT(S): Thirty-three women who had undergone cystectomy of the ovary or oophorectomy and were proved histopathologically to have cystic endometriosis in the ovary. INTERVENTION(S): Fifteen of the 33 patients were treated with GnRH agonists monthly for 2-6 months before surgery. The other 18 patients did not receive any hormonal therapy. Tissue sections were immunostained with an anti-E(1) sulfatase monoclonal antibody (KM1049) originating from human placenta. MAIN OUTCOME MEASURE(S): Microscopic evaluation to assess the presence and localization of E(1) sulfatase and to describe any variations in its expression with or without treatment with GnRH agonist. RESULT(S): Immunostaining showed that E(1) sulfatase was localized only on the glandular epithelial cells of cystic endometriosis in the ovary. The immunostaining with anti-E(1) sulfatase proved that GnRH agonist inhibited E(1) sulfatase expression in the cystic endometriosis in the ovary. CONCLUSION(S): Gonadotropin-releasing hormone agonist inhibits E(1) sulfatase expression in cystic endometriosis in the ovary.     

Hystérectomie pour endométriose : avec ou sans ovariectomie

The fate of the ovaries in hysterectomies performed for endometriosis remains controversial. Recent developments in laparoscopic surgery permit excision of the remaining ovary should there be a recurrence of the disorder, leading many to believe that an increasingly conservative approach should be taken.Objectives: to determine the proportion of oophorectomies performed in Quebec for endometriosis, the recurrence risk following hysterectomy, and conservative surgery of the ovaries based on current literature and the opinion of Quebec gynaecologists regarding this issue.Methods: the MED-ÉCHO computerized medical records of Quebec’s Ministère de la Santé were consulted between 1987 and 1991 for data on patients admitted with a diagnosis of endometriosis who underwent hysterectomy, with or without bilateral oophorectomy (10,102 patients). The literature on the recurrence risk of endometriosis following conservative surgery was reviewed. A questionnaire was sent to members of the Association of Obstetricians and Gynaecologists of Quebec in order to determine their opinion regarding surgery for endometriosis.Results: the proportion of hysterectomies with bilateral oophorectomies in women hospitalized for endometriosis in Quebec was 20.9 percent for women below the age of 35, 24.9 percent for those aged 35 to 39, 33.2 percent for those aged 40 to 44, and 55.9 percent for women aged 45 to 49. Current literature estimates the recurrence risk of endometriosis following hysterectomy and conservative surgery of the ovaries at 7.2 percent. Almost 80 percent of Quebec gynaecologists estimated the recurrence risk of endometriosis to be below 25 percent when one healthy ovary was left after removal of all macroscopic lesions.Conclusion: as previously seen in other specialties and for unknown reasons, there is a discrepancy between knowledge and current practice among Quebec gynaecologists concerning this matter. Recent advances in laparoscopic surgery allow us to treat recurrences. The percentage of such recurrences following hysterectomy and conservative surgery of the ovaries is low. It is, therefore, recommended that less bilateral oophorectomies be performed for endometriosis before menopause.     

GnRH analogues,transvaginal ultrasound-guided drainage and intracystic injection of recombinant interleukin-2 in the treatment of endometriosis

We performed a double-blind, randomised controlled trial to evaluate the results of ultrasound-guided aspiration of endometriomas under the effect of GnRH analogues and a possible additional beneficial effect by leaving 600000 IU of recombinant interleukin-2 (rIL-2) in the cysts. Twenty-four women with endometriosis-related symptoms, increased values of CA-125 and transvaginal ultrasonography showing endometriomas >3 cm who were initially sent to us for laparotomy and conservative surgery for endometriosis were included. Main outcome measures were severity of symptoms, size and percentage of echographical reduction of endometriomas and CA-125 levels after 2 menses post-GnRH analogues. Secondary outcome measures were the time until recurrence of abnormal parameters and the need for surgery after treatment. We found moderate clinical results after treatment with drainage plus GnRH analogues and significantly improved results in women having received rIL-2 intracystically. There were no side effects. Two out of 3 previously infertile patients became pregnant after therapy. Though the rates of recurrence of endometriomas >or=3 cm were similar in both groups, the period until recurrence was significantly greater when rIL-2 was used, and the rates of recurrence of symptoms and increased CA-125 values were also significantly lower in patients who received rIL-2. Surgery was finally performed on 10 patients (4 with and 6 without previous rIL-2 treatment) during follow-up (30 +/- 12.7 months). These findings led to the conclusion that transvaginal ultrasound-guided puncture and aspiration of endometriomas under endometrial suppressive therapy with GnRH analogues have some value for endometriosis treatment, improving the clinical manifestations and avoiding some surgical therapies, and that rIL-2 left in the cyst increases these beneficial effects significantly.     

Gonadotropin-releasing hormone agonist plus "add-back" hormone replacement therapy for treatment of endometriosis: a prospective, randomized, placebo-controlled, double-blind trial

OBJECTIVE: To assess the effect of add-back therapy with continuous combined estrogen-progestin on the GnRH agonist-induced hypoestrogenic state and its effectiveness in healing of endometriotic lesions. DESIGN: A prospective, randomized, placebo-controlled, double-blind trial. SETTING: Multiple centers in The Netherlands. PATIENT(S): 41 premenopausal women with laparoscopically diagnosed endometriosis (revised American Fertility Society scores >/=2). INTERVENTION(S): Patients were randomly assigned to receive a subcutaneous depot formulation of goserelin, 3. 6 mg, every 4 weeks, plus oral placebo or oral continuous combined estradiol-norethisterone acetate add-back therapy daily for 24 weeks. MAIN OUTCOME MEASURE(S): Endometriosis response, bone mineral density, transvaginal ultrasonographic changes, endocrinologic effects, and subjective side effects. RESULT(S): The number of endometriotic implants was significantly reduced in both groups. In the group that received GnRH agonist plus placebo, bone mineral density of the lumbar spine decreased by 5.02%. CONCLUSION(S): The effectiveness of GnRH agonist treatment for endometriosis was not decreased by the addition of add-back continuous combined hormone replacement therapy. Bone mineral density of the lumbar spine was maintained and subjective side effects were diminished.     

Conservative treatment of deep infiltrating endometriosis: review of existing options

Endometriosis with its estimated incidence rate of ～7–10% of women of reproductive age is a disease with the wide spectrum of symptoms depending on form and localization of endometrial foci. One clinical form of endometriosis is deep infiltrating endometriosis (DIE), most difficult to manage and generating a lot of direct and indirect treatment costs. We search the literature from PubMed database to establish the role of conservative treatment of DIE. Randomised controlled trials are lacking but in experts opinion hormonal treatment should be the first-line treatment in DIE. After evaluation of pain or other symptoms, second-line therapy with GnRH analogs or danazol should be offered or minimally invasive surgery. Consensus is not made whether surgery is the best therapeutic treatment for affected patients. Strong depending on surgeon’s experience conservative surgery should be offered if the total excision of DIE foci is possible, which is essential for a successful outcome. If available treatment options do not release pain associated with DIE, experimental treatment in clinical trials should be discussed with patients.     

GnRH-Analoga in der Endometriosetherapie

GnRH analogues are currently the most effective medications used to achieve regression of islands of endometriosis and attenuate endometriosis-related symptoms. In combination with low-dose add-back medication they are effective and their side effects are few and tolerable. The different types of GnRH analogues available in Germany do not differ in effectiveness, but patient compliance is best with depot preparations. Whether GnRH analogues are used after or instead of surgery, to prevent recurrences or to treat recurrences depends on the individual situation of the patient and on the proliferative activity, localisation, type and stage of the endometriosis.     

Endometriosis related infertility

From the literature, the crucial knowledge were drawn among endometriosis related infertility. Endometriosis is an important factor of infertility in minimal or light stages and a major one in mild or moderate stages. Thus, a laparoscopy must be performed to confirm endometriosis when suggestive clinical or biological signs exist. In absence of them, laparoscopy can be delayed after intra-uterine inseminations (IUI). The first line treatment is laparoscopic surgery. Its efficacy is proven. It is useless to prescribe a post-operative medical treatment (GnRH analogues). Surgery leads to 25 to 40% of deliveries. It is dependant on age, infertility duration, tubo-ovarian adhesion and tubes involvement. But, surgery can be avoided and the patient is directly referred to In Vitro Fertilization (IVF) when the lesions extension is so important that surgery exposes to complications or when there is a permanent other indication for IVF (severe male infertility). When infertility persists 6 to 12 months after surgery and without patent recurrence, ovulation stimulations and IUI are performed as the second line treatment. After IUI failure, or in case of recurrence, IVF must be applied. A second surgery is not recommended. The IVF results are not impaired by the presence of endometriosis and even of endometriomas. Thus, it is useless to operate again endometriosis before IVF. In opposition, in severe stages or in cases of recurrence, a pre-IVF medical treatment (GnRH analogues) improves the results. IVF do not increased the risk of endometriosis acute growth. In case of infertility and pain, infertility is considered as the first target. But medical treatment can be prescribed between the IVF attempts.     

保守性手术联合长效醋酸甲羟孕酮治疗中重度子宫内膜异位症的临床观察

目的　探讨长效醋酸甲羟孕酮 (DMPA)用于中重度子宫内膜异位症患者保守性手术后巩固治疗的临床效果及副反应。方法　将资料完整的中重度子宫内膜异位症行保守性手术治疗的患者 94例 ,分为DMPA组、促性腺激素释放激素激动剂 (GnRH a)组及对照组。DMPA组 34例 ,术后月经来潮 5d内 ,深部肌内注射DMPA 15 0mg ,2 8～ 30d注射 1次 ,共 6次 ;GnRH a组 30例 ,术后月经来潮 5d内 ,皮下注射亮丙瑞林 3 75mg ,2 8～ 30d注射 1次 ,共 6次 ;对照组 30例 ,术后未用药物治疗。观察治疗前后患者疼痛症状和体征的临床缓解情况、月经变化、体重改变、肝肾功能及性激素水平变化。结果　DMPA组及GnRH a组患者疼痛症状和体征完全缓解率分别为 88%及 93% ,显著高于对照组的 5 3% ,差异有统计学意义 (χ2 =12 2 73,P <0 0 1;χ2 =9 6 0 4 ,P <0 0 1) ,DMPA组及GnRH a组患者累积复发率分别为 6 %及 7% ,显著低于对照组的 2 7% (χ2 =5 2 2 2 ,P <0 0 5 ;χ2 =4 32 0 ,P <0 0 5 ) ,而DMPA组与GnRH a组比较 ,差异无统计学意义 (χ2 =0 4 88,P >0 0 5 ;χ2 =0 0 17,P >0 0 5 )。DMPA组用药前雌二醇水平为 (2 0 0± 15 ) pmol/L ,用药后雌二醇水平显著下降至(12 0± 9) pmol/L ,但仍维持在卵泡早期水平。GnRH a组用药前     

阴道子宫内膜异位症18例临床分析

目的:探讨阴道子宫内膜异位症(内异症)的临床特点和治疗效果。方法:回顾性分析我院2003年1月至2005年10月收治的18例经病理证实为阴道内异症患者的临床资料。结果:阴道内异症独立存在者13例(72.2%),合并盆腔内异症者5例(27.8%)。前组性交痛及合并妇科良、恶性肿瘤的比例高于后组,而合并不孕的比例较后组低。所有患者中8例行保守性手术治疗,其中4例术后加用GnRHa治疗3个月;其余10例均行根治性手术治疗。平均随访18.6月,共有2例复发(11.1%),均见于肿块直径≥3 cm、行阴道局部切除未用药物治疗者。总共半年累积复发率13.3%(2/15),保守性手术复发为25%(2/8),其半年累积复发率40.0%(2/5);保守性手术术后加用药物治疗者及行根治性手术者无复发。各种术式之间比较,无明显统计学差异(P>0.05)。结论:阴道子宫内膜异位症与常见的盆腔内异症相比较,有其特殊之处。其发生机制可能与盆腔内异症不同,尚有待进一步研究。     

Unusually rapid growth of bilateral endometriomas and acute bilateral hydronephrosis

Ultrasonography can detect ovarian endometriomas, but negative findings cannot exclude other localizations of endometriosis, especially in symptomatic patients. We describe a case of sudden development of large bilateral endometriomas after a series of negative ultrasound scans, causing bilateral hydronephrosis. Our patient is a 32-year-old nulligravida with long-lasting dysmenorrhea, urinary symptoms, and familiarity for endometriosis, who had voluntarily discontinued oral contraceptives. Various pelvic scans had not shown pathological findings. Five months following the last negative scan, she presented with pain and increase of abdominal girth. Ultrasonography and computed tomography showed large ovarian cysts (16?cm?right – 10?cm?left) and hydronephrosis bilaterally. She underwent conservative surgery followed by GnRH analogs. At a 6-months follow-up, she was symptom-free and ultrasonography showed no recurrence. Endometriosis has still an unknown mechanism of proliferation and its clinical behavior or progression is highly unpredictable. Severe uropathy is commonly related to direct ureteral involvement, but can also depend on an ab-extrinseco compression by large, rapidly growing endometriomas. Women at risk of endometriosis, who are not receiving empirical medical treatment, should be adequately and regularly assessed via pelvic ultrasonography and/or submitted to diagnostic laparoscopy in order to prevent serious consequences such as silent renal loss.     

Effect of interferon alpha-2b on endometrioma cells in vitro

OBJECTIVE: To examine the effect of interferon alpha-2b on the growth of endometrioma cells and its effect on the DNA synthesis. METHODS: Cells from four separate endometrioma cell lines were seeded into six-well plates in M199 medium containing increasing levels of interferon alpha-2b: 0 (control), 50, 100, 500, 1000, and 2000 U/mL. All cells were counted on days 0, 3, 6, and 9 in quadruplicate, and the counts were averaged for each condition. A second experiment was run to demonstrate the effect of short-term exposure of interferon alpha-2b on the growth of endometrioma cells in culture. In a separate experiment, cells from two endometriomas were plated in quadruplicate to evaluate the DNA synthesis. On day 3, 1000 and 4000 U/mL of interferon alpha-2b were added and run simultaneously with control (0 U/mL) wells. 3H-thymidine was added to each condition for 24 and 48 hours' incubation. Cells were then harvested and counted in a scintillation counter to study the 3H-thymidine uptake. RESULTS: Interferon alpha-2b suppressed endometrioma cell growth in vitro. This effect increased with increasing concentrations of interferon alpha-2b (50-2000 U/mL) compared with the control (0 U/mL). The suppression of cell growth was statistically significant, but when interferon alpha-2b was removed from the culture cell growth increased. 3H-thymidine uptake by endometrioma cells decreased compared with the control after 24 and 48 hours for interferon alpha-2b concentrations of 1000 and 4000 U/mL, respectively. CONCLUSION: Interferon alpha-2b inhibits the growth and DNA synthesis of endometrioma cells in culture. This finding may have prospects for the treatment of endometriosis.     

Long-term personalized GnRH agonist therapy without estrogen supplementation for recurrent endometriotic catamenial pneumothorax--case report

A patient with diaphragmatic endometriosis who showed immediate relapse following radical thoracoscopic surgery received personalized GnRH agonist (GnRHa) therapy. GnRHa depots were subcutaneously injected by modulating injection intervals according to serum estradiol and LH levels in order to maintain long-term amenorrhea without any adverse effects. A leuprolide acetate depot was injected 24 times for 34 months. Therefore, so far, 1.88 mg of leuprolide acetate depot have been injected every seven weeks to achieve a stable endocrine condition with 15-30 pg/ml serum estradiol, 3-10 IU/l serum LH, and 7-15 IU/lI serum FSH.     

Increased pregnancy rates after ultralong postoperative therapy with gonadotropin-releasing hormone analogs in patients with endometriosis

OBJECTIVE: To examine whether ultralong GnRH analog (GnRH-a) therapy after surgical treatment of endometriosis and before ART influences the pregnancy rate. DESIGN: Prospective, randomized, controlled study. SETTING: University clinic for reproductive medicine and gynecologic endocrinology. PATIENT(S): One hundred ten patients with stage II to IV endometriosis according to ASRM criteria. INTERVENTION(S): Fifty-five patients received GnRH-a for 6 months after surgery and subsequently underwent up to 3 cycles of ART, and 55 patients received 3 cycles of ART alone immediately after surgery. MAIN OUTCOME MEASURE(S): Clinical pregnancy rates. RESULTS: The pregnancy rate per patient was higher among patients who received follow-up treatment with GnRH-a. The same results were found in patients with stage III or IV endometriosis who were undergoing IUI or IVF/ICSI. CONCLUSION(S): Ultralong GnRH-a therapy increases the pregnancy rate of ART in patients with severe endometriosis.     

Safety of conservative management and fertility outcome in women with borderline tumors of the ovary

OBJECTIVE: To assess the safety of fertility-sparing treatment and the remaining chance of childbearing after surgery. DESIGN: Retrospective clinical study. DESIGN: Gynecology department of a university teaching hospital. PATIENT(S): Seventy-five women underwent surgical management in our institution between 1986 and 2001 for borderline tumors of the ovary. INTERVENTION(S): Fifty-nine patients were treated by radical, fertility-compromising surgery. The remaining 16 patients underwent conservative surgery, preserving the uterus and at least some functional ovarian tissue. Seven unilateral adnexectomies, one simple cystectomy, and two adnexectomies associated with contralateral cystectomy were performed. MAIN OUTCOME MEASURE(S): Recurrence, survival, and pregnancy rates. RESULT(S): The observed recurrence rates after radical and conservative surgery were 0.0% and 18.7%, respectively. No disease-related deaths occurred in any group; there is no significant difference in survival rates. We can report 12 pregnancies in 7 of 11 women who underwent fertility-sparing management and who wished to become pregnant. CONCLUSION(S): In certain circumstances, conservative management offers a safe solution for borderline tumors of the ovary. Recurrence is noted significantly more often after this type of treatment, but all cases of recurrent disease can be detected with close follow-up and can be treated accordingly. No significant change in survival rates was found. Moreover, the pregnancy rate in women desiring pregnancy, those treated conservatively, was as high as 63.6%.