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Conservative surgery versus expectant management for the infertile patient with mild endometriosis
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I
FERTllJTY AND STERILITY Copyright c 1982 The American Fertility Society
Vol. 37, No.2, February 1982 Printed in U.SA.
Conservative surgery versus expectant management for the infertile patient with mild endometriosis
Robert S. Schenken, M.D. * L. Russell Malinak, M.D., F.A.C.O.G. t The University of Texas Health Science Center at San Antonio, San Antonio, Texas 78284, and Baylor College of Medicine, Houston, Texas 77025
During an 8 -year period, the records of 90 patients with mild pelvic endometriosis diagnosed by endoscopy were reviewed to determine whether conservative surgical treatment resulted in higher pregnancy rates than expectant management. Forty-five patients were found to have mild endometriosis as the only abnormality in a complete fertility workup. Sixteen patients were managed expectantly, and 75% became pregnant in 1 year. Twenty-nine patients had conservative surgery, and 72.4% conceived in 1 year. This surgery-to-pregnancy interval was similar in both groups. Sixty patients had mild endometriosis only or mild endometriosis and anovulation corrected by clomiphene citrate. The pregnancy rate in 1 year was 722% in 18 patients managed expectantly and 762% in 42 patients treated with conservative surgery. The surgery-to-pregnancy interval was 5 and 6 months, respectively. These results suggest that expectant management should be considered prior to medical or surgical treatment of infertile patients with mild endometriosis. Fertil Steril 37:183,1982
It is generally accepted that there is a relationship between endometriosis and infertility.I-4 Although previous studies have shown that 6% to 30% of patients evaluated for infertility have endometriosis as the only abnormal finding, the mechanism by which endometriosis interferes with conception is unknown. 3 , 5, 6 Clearly, patients with large ovarian endometriomas, pelvic adhesions, and distorted anatomy may be infertile due to mechanical interference with ovulation, ovum pick-up, and ovum transport. However, it is difficult to explain the cause
Received July 13, 1981; revised and accepted October 8, 1981. *Reprint requests: Robert S. Schenken, M.D., Department of Obstetrics and Gynecology, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, Texas 78284. tDepartment of Obstetrics and Gynecology, Baylor College of Medicine. Vol. 37, No.2, February 1982
of infertility in patients with mild endometriosis and no distortion of pelvic anatomy. In spite of our meager understanding of the pathophysiology of infertility in patients with mild endometriosis, pregnancy rates after medicalor surgical attempts to ablate the ectopic endometrium are quite acceptable. Recently, studies by Garcia and Decker have questioned the need to treat patients with mild endometriosis. 1, 7 These studies demonstrated that pregnancy rates after expectant management were similar to pregnancy rates after conservative surgery. The purpose of this report is to evaluate this observation by comparison of conservative surgery and expectant management for patients with mild endometriosis. MATERIALS AND METHODS
During an 8-year period from December 1971 to -December 1979, 134 patients were diagnosed as having mild endometriosis. The diagnosis was made by endoscopy and confirmed histologically
Schenken and Malinak Treatment of mild endometriosis
183
Table 1. Clinical Data of Patients with Mild Endometriosis Undergoing Endoscopy Only or Endoscopy and Conservative Surgery No. of patients
Endoscopy Conservative surgery
69
Total
90
21
Age
27.5 28.1
in all patients undergoing laparotomy when tissue was obtained. All of the patients were from the private practice of Dr. Malinak. Ninety patients met the retrospective study criteria of (1) primary or secondary infertility for greater than 1 year; (2) complete infertility evaluation including documentation of ovulation by menstrual history, basal body temperature charts, luteal phase progesterone, and/or endometrial biopsy, evaluation of tubal patency by hysterosalpingogram, and evaluation of the male factor by semen analysis; (3) no hormonal therapy before or after diagnosis; and (4) attempting pregnancy for at least 12 months after diagnosis. A patient whose record ended less than 12 months after diagnosis was considered "lost to follow-up" and excluded from the study. All patients initially underwent diagnostic endoscopy, dilatation, and endometrial biopsy. Prior to endoscopy, all patients were apprised of the risks and benefits of performing a conservative surgical procedure under the same anesthetic if endometriosis was discovered. The patients were not randomly assigned to endoscopy or endoscopy with conservative surgery prior to the procedure. When the patient consented, conservative surgery was performed. This included resection of endometrial implants, presacral neurectomy, uterosacral ligament implication, and uterine suspension when retrodisplacement was present. 8 Fischer Exact Probability and the two tailed t-test were used for statistical analysis where appropriate.
Nulliparous
Symptomatic
%
%
65.0 66.1
69.0
65.0
Duration of infertility
33 months 34 months
surgery. Sixty-one patients underwent endoscopy and conservative surgery. The age, parity, presence of symptomatology other than infertility, and duration of infertility were similar in both groups (Table 1). Forty-five patients were found to have mild endometriosis as the only abnormal finding in the infertility evaluation, 15 had mild endometriosis and anovulation, and 30 had mild endometriosis plus another infertility factor other than anovulation (Table 2). Sixteen patients with mild endometriosis alone underwent diagnostic endoscopy without conservative surgery, and 12 conceived, for a pregnancy rate of 75%. Twenty-one of 29 patients undergoing conservative surgery conceived, for a pregnancy rate of 75%. The mean duration from operation to pregnancy was 5 months after endoscopy alone and 4 months after conservative surgery. The differences in pregnancy rates and operation to pregnancy interval were not significant (Table 3).
When patients with mild endometriosis and anovulation corrected by clomiphene citrate were considered with the patients with endometriosis only, the pregnancy rates were 72.2% in the group undergoing endoscopy and 76.2% in the group undergoing conservative surgery. Again, the differences in pregnancy rates and the operation-to-pregnancy interval were not significant. Conservative surgery was eventually performed in the five patients who failed to conceive after endoscopic diagnosis of mild endometriosis. Two of these patients became pregnant, 7 and 17 months after laparotomy. Of the 30 patients with mild endometriosis and other infertility factors, 3 became pregnant after conservative surgery (11.1%). None of the 3 patients became pregnant after endoscopic diagnosis alone.
RESULTS Ninety patients with mild endometriosis met the criteria for this retrospective study. Twentyone patients opted for endoscopy to confirm the diagnosis but elected to postpone conservative Table 2. Infertility Factors in Patients with Mild Endometriosis
Endoscopy Conservative surgery
184
Endometriosis and corrected anovulation
Endometriosis and other factors
16
2
29
13
3 27
No. of patients
Endometriosis only
21
69
Schenken and Malinak Treatment of mild endometriosis
Fertility and Sterility
Table 3. Pregnancy Rates and Interval from Diagnosis to Conception After Endoscopic Diagnosis Only or Conservative Surgery Endometriosis only and endometriosis with corrected anovulation
Endometriosis only
Endoscopy Conservative surgery
No.pa, tients
No. preg' nant
%
Surgery-. pr:f' nancy interv
No.pa, tients
No. preg' nant
%
Surgery-preg, 'nancy
16 29
12 21
75.0 72.4
5 months 4 months
18 42
13 32
72.2 76.2
5 months 6 months
P - 0.24 (NS)
P = 0.27 (NS)
DISCUSSION
Infertility patients with mild endometriosis have classically been treated medically or surgically to ablate the ectopic endometrium. Certainly, the success of such treatment has been rewarding, but recent reports in the literature have demonstrated similar pregnancy rates without 1 7 These observations suggest SpeCl'fiCt reatment.' that treatment of mild endometriosis does not improve fertility. In this study we set out to determine the efficacy of conservative surgical treatment of mild endometriosis for improving fertility. Pregnancy rates of 75% were found when patients were managed expectantly and 72.4% after conservative surgery for patients with· endometriosis as the only finding in a complete infertility workup. When patients with endometriosis alone and endometriosis with anovulation corrected by clomiphene citrate were combined, the pregnancy rates were 72.2% without surgery and 76.2% after conservative surgery. Similar pregnancy rates have been reported by others after conservative surgery, medical therapy, and laparoscopic electrocoagulation for mild pelvic endometriosis. The pregnancy rate after conservative surgery is reported to be as high as 88%.9 Treatment of mild endometriosis with danazol, medroxyprogesterone, methyltestosterone, and pseudopregnancy regimens have resulted in pregnancy rates of 5% to 72%.10-13 Laparoscopic electrocoagulation has resulted in a pregnancy rate of 48%.14, 15 Unfortunately, control groups were not used in these studies, and comparing their results with ours is inappropriate. Nevertheless, the high pregnancy rate without treatment in this study certainly suggests that initial treatment of patients with mild endometriosis solely to improve fertility is unnecessary. There are other problems with immediate medical or surgical therapy for endometriosis. Conservative surgery requires the patient to undergo a major operation with attendant costs and risks. Vol. 37, No.2, February 1982
Medical treatment is costly and uses time in which patients might attempt to become pregnant. Laparoscopic electrocoagulation risks damage to adjacent pelvic structures and perhaps injury to the ureter. The main advantage of these treatments is to relieve symptoms other than infertility. Relief of pelvic pain, dysmenorrhea, and dyspareunia has been clearly demonstrated by these therapeutic approaches. Clearly, no specific relief of these symptoms should be expected without treatment. Nevertheless, nonhormonal medical treatment may provide symptomatic relief. Such medications include mild oral analgesics and antiprostaglandin drugs for dysmenorrhea. The reassurance of a 75% pregnancy rate within 1 year is also helpful to most patients. In view ofthe findings of this study, we recommend that infertility patients with recently diagnosed mild endometriosis be managed expectantly as long as symptoms of dysmenorrhea, dyspareunia, and pelvic pain can be controlled with nonhormonal therapy. During this observation period, every effort should be made to correct other infertility factors, especially anovulation. Patients who fail to conceive after 1 year of observation or patients who present late in their reproductive years may be best served with immediate medical or surgical treatment.
REFERENCES 1. Garcia CR, Davis SS: Pelvic endometriosis: infertility and pelvic pain. Am J Obstet Gyneco1129:740, 1977 2. Andrews WC: Endometriosis. OB/GYN Digest, March 1977, p 14 3. Spangler DB, Jones GS, Jones HW: Infertility due to en, dometriosis. Am J Obstet Gynecol 190:850, 1971 4. Rubin IC: Sterility. Obstet Gynecol 3:161,1933 5. Cohen MR: Endometriosis and infertility. J Reprod Med 18:209, 1977 6. Schenken RS, Asch RH: Surgical induction of endometriosis in the rabbit: effects on fertility and peritoneal fluid prostaglandins. Fertil Steril 34:581, 1980 7. Decker HW, Lopez H: Conservative surgical treatment of endometriosis and infertility. Infertility 2:155, 1979
Schenken and Malinak Treatment of mild endometriosis
185
8. Malinak LR: Management of endometriosis in the infertile female. In The Infertile Female, Edited by JR Givens. Chicago, Yearbook Medical Publishers, 1979, p 359 9. Ranny B: Endometriosis; I. Conservative operations. Am J ObstetGynecol 107:743, 1970 10. Dmowski WP, Cohen MR: Antigonadotropin (danazol) in the treatment of endometriosis. Am J Obstet Gynecol 130:41, 1978 11. Moghissi KS, Boyce CR: Management of endometriosis with oral medroxyprogesterone acetate. Obstet Gynecol 47:265, 1976
188
Schenken and Malinak Treatment of mild endometriosis
12. Katayama KP, Manuel M, Jones HW Jr, Jones GS: Methyltestosterone treatment of infertility associated with pelvic endometriosis. Fertil Steril 27:83, 1976 13. Andrews WC, Larsen GD: Endometriosis: treatment with hormonal pseudopregnancy and/or operation. Am J Obstet GynecoI118:643, 1974 14. Hasson HM: Electrocoagulation of pelvic endometriotic lesions with laparoscopic control. Am J Obstet Gynecol 135:115,1979 15. Sulewski JM, Curcio FD, Bronitsky C, Stenger VG: The treatment·of endometriosis at laparoscopy for infertility. Am J Obstet GynecolI38:128, 1980
Fertility and Sterility
I
FERTllJTY AND STERILITY Copyright c 1982 The American Fertility Society
Vol. 37, No.2, February 1982 Printed in U.SA.
Conservative surgery versus expectant management for the infertile patient with mild endometriosis
Robert S. Schenken, M.D. * L. Russell Malinak, M.D., F.A.C.O.G. t The University of Texas Health Science Center at San Antonio, San Antonio, Texas 78284, and Baylor College of Medicine, Houston, Texas 77025
During an 8 -year period, the records of 90 patients with mild pelvic endometriosis diagnosed by endoscopy were reviewed to determine whether conservative surgical treatment resulted in higher pregnancy rates than expectant management. Forty-five patients were found to have mild endometriosis as the only abnormality in a complete fertility workup. Sixteen patients were managed expectantly, and 75% became pregnant in 1 year. Twenty-nine patients had conservative surgery, and 72.4% conceived in 1 year. This surgery-to-pregnancy interval was similar in both groups. Sixty patients had mild endometriosis only or mild endometriosis and anovulation corrected by clomiphene citrate. The pregnancy rate in 1 year was 722% in 18 patients managed expectantly and 762% in 42 patients treated with conservative surgery. The surgery-to-pregnancy interval was 5 and 6 months, respectively. These results suggest that expectant management should be considered prior to medical or surgical treatment of infertile patients with mild endometriosis. Fertil Steril 37:183,1982
It is generally accepted that there is a relationship between endometriosis and infertility.I-4 Although previous studies have shown that 6% to 30% of patients evaluated for infertility have endometriosis as the only abnormal finding, the mechanism by which endometriosis interferes with conception is unknown. 3 , 5, 6 Clearly, patients with large ovarian endometriomas, pelvic adhesions, and distorted anatomy may be infertile due to mechanical interference with ovulation, ovum pick-up, and ovum transport. However, it is difficult to explain the cause
Received July 13, 1981; revised and accepted October 8, 1981. *Reprint requests: Robert S. Schenken, M.D., Department of Obstetrics and Gynecology, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, Texas 78284. tDepartment of Obstetrics and Gynecology, Baylor College of Medicine. Vol. 37, No.2, February 1982
of infertility in patients with mild endometriosis and no distortion of pelvic anatomy. In spite of our meager understanding of the pathophysiology of infertility in patients with mild endometriosis, pregnancy rates after medicalor surgical attempts to ablate the ectopic endometrium are quite acceptable. Recently, studies by Garcia and Decker have questioned the need to treat patients with mild endometriosis. 1, 7 These studies demonstrated that pregnancy rates after expectant management were similar to pregnancy rates after conservative surgery. The purpose of this report is to evaluate this observation by comparison of conservative surgery and expectant management for patients with mild endometriosis. MATERIALS AND METHODS
During an 8-year period from December 1971 to -December 1979, 134 patients were diagnosed as having mild endometriosis. The diagnosis was made by endoscopy and confirmed histologically
Schenken and Malinak Treatment of mild endometriosis
183
Table 1. Clinical Data of Patients with Mild Endometriosis Undergoing Endoscopy Only or Endoscopy and Conservative Surgery No. of patients
Endoscopy Conservative surgery
69
Total
90
21
Age
27.5 28.1
in all patients undergoing laparotomy when tissue was obtained. All of the patients were from the private practice of Dr. Malinak. Ninety patients met the retrospective study criteria of (1) primary or secondary infertility for greater than 1 year; (2) complete infertility evaluation including documentation of ovulation by menstrual history, basal body temperature charts, luteal phase progesterone, and/or endometrial biopsy, evaluation of tubal patency by hysterosalpingogram, and evaluation of the male factor by semen analysis; (3) no hormonal therapy before or after diagnosis; and (4) attempting pregnancy for at least 12 months after diagnosis. A patient whose record ended less than 12 months after diagnosis was considered "lost to follow-up" and excluded from the study. All patients initially underwent diagnostic endoscopy, dilatation, and endometrial biopsy. Prior to endoscopy, all patients were apprised of the risks and benefits of performing a conservative surgical procedure under the same anesthetic if endometriosis was discovered. The patients were not randomly assigned to endoscopy or endoscopy with conservative surgery prior to the procedure. When the patient consented, conservative surgery was performed. This included resection of endometrial implants, presacral neurectomy, uterosacral ligament implication, and uterine suspension when retrodisplacement was present. 8 Fischer Exact Probability and the two tailed t-test were used for statistical analysis where appropriate.
Nulliparous
Symptomatic
%
%
65.0 66.1
69.0
65.0
Duration of infertility
33 months 34 months
surgery. Sixty-one patients underwent endoscopy and conservative surgery. The age, parity, presence of symptomatology other than infertility, and duration of infertility were similar in both groups (Table 1). Forty-five patients were found to have mild endometriosis as the only abnormal finding in the infertility evaluation, 15 had mild endometriosis and anovulation, and 30 had mild endometriosis plus another infertility factor other than anovulation (Table 2). Sixteen patients with mild endometriosis alone underwent diagnostic endoscopy without conservative surgery, and 12 conceived, for a pregnancy rate of 75%. Twenty-one of 29 patients undergoing conservative surgery conceived, for a pregnancy rate of 75%. The mean duration from operation to pregnancy was 5 months after endoscopy alone and 4 months after conservative surgery. The differences in pregnancy rates and operation to pregnancy interval were not significant (Table 3).
When patients with mild endometriosis and anovulation corrected by clomiphene citrate were considered with the patients with endometriosis only, the pregnancy rates were 72.2% in the group undergoing endoscopy and 76.2% in the group undergoing conservative surgery. Again, the differences in pregnancy rates and the operation-to-pregnancy interval were not significant. Conservative surgery was eventually performed in the five patients who failed to conceive after endoscopic diagnosis of mild endometriosis. Two of these patients became pregnant, 7 and 17 months after laparotomy. Of the 30 patients with mild endometriosis and other infertility factors, 3 became pregnant after conservative surgery (11.1%). None of the 3 patients became pregnant after endoscopic diagnosis alone.
RESULTS Ninety patients with mild endometriosis met the criteria for this retrospective study. Twentyone patients opted for endoscopy to confirm the diagnosis but elected to postpone conservative Table 2. Infertility Factors in Patients with Mild Endometriosis
Endoscopy Conservative surgery
184
Endometriosis and corrected anovulation
Endometriosis and other factors
16
2
29
13
3 27
No. of patients
Endometriosis only
21
69
Schenken and Malinak Treatment of mild endometriosis
Fertility and Sterility
Table 3. Pregnancy Rates and Interval from Diagnosis to Conception After Endoscopic Diagnosis Only or Conservative Surgery Endometriosis only and endometriosis with corrected anovulation
Endometriosis only
Endoscopy Conservative surgery
No.pa, tients
No. preg' nant
%
Surgery-. pr:f' nancy interv
No.pa, tients
No. preg' nant
%
Surgery-preg, 'nancy
16 29
12 21
75.0 72.4
5 months 4 months
18 42
13 32
72.2 76.2
5 months 6 months
P - 0.24 (NS)
P = 0.27 (NS)
DISCUSSION
Infertility patients with mild endometriosis have classically been treated medically or surgically to ablate the ectopic endometrium. Certainly, the success of such treatment has been rewarding, but recent reports in the literature have demonstrated similar pregnancy rates without 1 7 These observations suggest SpeCl'fiCt reatment.' that treatment of mild endometriosis does not improve fertility. In this study we set out to determine the efficacy of conservative surgical treatment of mild endometriosis for improving fertility. Pregnancy rates of 75% were found when patients were managed expectantly and 72.4% after conservative surgery for patients with· endometriosis as the only finding in a complete infertility workup. When patients with endometriosis alone and endometriosis with anovulation corrected by clomiphene citrate were combined, the pregnancy rates were 72.2% without surgery and 76.2% after conservative surgery. Similar pregnancy rates have been reported by others after conservative surgery, medical therapy, and laparoscopic electrocoagulation for mild pelvic endometriosis. The pregnancy rate after conservative surgery is reported to be as high as 88%.9 Treatment of mild endometriosis with danazol, medroxyprogesterone, methyltestosterone, and pseudopregnancy regimens have resulted in pregnancy rates of 5% to 72%.10-13 Laparoscopic electrocoagulation has resulted in a pregnancy rate of 48%.14, 15 Unfortunately, control groups were not used in these studies, and comparing their results with ours is inappropriate. Nevertheless, the high pregnancy rate without treatment in this study certainly suggests that initial treatment of patients with mild endometriosis solely to improve fertility is unnecessary. There are other problems with immediate medical or surgical therapy for endometriosis. Conservative surgery requires the patient to undergo a major operation with attendant costs and risks. Vol. 37, No.2, February 1982
Medical treatment is costly and uses time in which patients might attempt to become pregnant. Laparoscopic electrocoagulation risks damage to adjacent pelvic structures and perhaps injury to the ureter. The main advantage of these treatments is to relieve symptoms other than infertility. Relief of pelvic pain, dysmenorrhea, and dyspareunia has been clearly demonstrated by these therapeutic approaches. Clearly, no specific relief of these symptoms should be expected without treatment. Nevertheless, nonhormonal medical treatment may provide symptomatic relief. Such medications include mild oral analgesics and antiprostaglandin drugs for dysmenorrhea. The reassurance of a 75% pregnancy rate within 1 year is also helpful to most patients. In view ofthe findings of this study, we recommend that infertility patients with recently diagnosed mild endometriosis be managed expectantly as long as symptoms of dysmenorrhea, dyspareunia, and pelvic pain can be controlled with nonhormonal therapy. During this observation period, every effort should be made to correct other infertility factors, especially anovulation. Patients who fail to conceive after 1 year of observation or patients who present late in their reproductive years may be best served with immediate medical or surgical treatment.
REFERENCES 1. Garcia CR, Davis SS: Pelvic endometriosis: infertility and pelvic pain. Am J Obstet Gyneco1129:740, 1977 2. Andrews WC: Endometriosis. OB/GYN Digest, March 1977, p 14 3. Spangler DB, Jones GS, Jones HW: Infertility due to en, dometriosis. Am J Obstet Gynecol 190:850, 1971 4. Rubin IC: Sterility. Obstet Gynecol 3:161,1933 5. Cohen MR: Endometriosis and infertility. J Reprod Med 18:209, 1977 6. Schenken RS, Asch RH: Surgical induction of endometriosis in the rabbit: effects on fertility and peritoneal fluid prostaglandins. Fertil Steril 34:581, 1980 7. Decker HW, Lopez H: Conservative surgical treatment of endometriosis and infertility. Infertility 2:155, 1979
Schenken and Malinak Treatment of mild endometriosis
185
8. Malinak LR: Management of endometriosis in the infertile female. In The Infertile Female, Edited by JR Givens. Chicago, Yearbook Medical Publishers, 1979, p 359 9. Ranny B: Endometriosis; I. Conservative operations. Am J ObstetGynecol 107:743, 1970 10. Dmowski WP, Cohen MR: Antigonadotropin (danazol) in the treatment of endometriosis. Am J Obstet Gynecol 130:41, 1978 11. Moghissi KS, Boyce CR: Management of endometriosis with oral medroxyprogesterone acetate. Obstet Gynecol 47:265, 1976
188
Schenken and Malinak Treatment of mild endometriosis
12. Katayama KP, Manuel M, Jones HW Jr, Jones GS: Methyltestosterone treatment of infertility associated with pelvic endometriosis. Fertil Steril 27:83, 1976 13. Andrews WC, Larsen GD: Endometriosis: treatment with hormonal pseudopregnancy and/or operation. Am J Obstet GynecoI118:643, 1974 14. Hasson HM: Electrocoagulation of pelvic endometriotic lesions with laparoscopic control. Am J Obstet Gynecol 135:115,1979 15. Sulewski JM, Curcio FD, Bronitsky C, Stenger VG: The treatment·of endometriosis at laparoscopy for infertility. Am J Obstet GynecolI38:128, 1980
Fertility and Sterility