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Pregnancy after surgical treatment of deep infiltrative endometriosis
investigation of infertile patients without obvious pelvic pathology and early diagnosis of endometriosis. Design: Both surveys were international and based on confidential, selfreported cases. The definition was full thickness bowel injury. Materials/Methods: The SL survey was responded by members (n ⫽ 134) of the International Society of Gynecological Laparoscopy. All had previous, but variable experience with laparoscopy. The THL survey was responded by participants or their colleagues (n ⫽ 44) of the Second International Congress on Microendoscopy. They reported the initial experience with the Transvaginal hydrolaparoscope (Circon ACMI, Stamford, CT, USA) or Fertiloscope (Soprane, S.A., Lyon, France). The outer diameter of the instruments is respectively 3.9 and 6 mm. Results: A total of 23,540 SL’s with 40 bowel injuries and 3,667 THL’s with 24 bowel injuries were reported. In SL twenty-two (55%) injuries occurred during the access by the Veress needle (n ⫽ 7) and trocar (n ⫽ 15). With experience (performing more than 100 procedures a year) the risk decreased significantly from 0.5% to 0.1%, but access injuries remained as frequent as operative injuries. Four Veress needle injuries and all other diagnosed injuries were peroperatively repaired. The diagnosis was delayed in 7 (15%) patients of whom 2 (28%) died 7 days after surgery. All THL injuries occurred during the access and involved in 88% the extraperitoneal bowel. After 50 procedures the risk of injury decreased from 1.35% to 0.25%. All injuries were diagnosed during the procedure. The injury measured respectively between 2 an 5 mm for the transvaginal hydrolaparoscope and 5– 6 mm for the fertiloscope. None of the injuries showed leakage. Twenty-two (92%) were managed expectantly without complications. Conclusions: Although both surveys differ in recruitment and experience the risk of bowel injury is likely to be higher at THL than SL. However, the risk of undiagnosed bowel injury at ST is confirmed by this survey. A combined Veress needle trocar system may add to the safety by allowing diagnosis at the time of the insertion of the Veress needle. The major safety factor of THL is the small size injury of not more than 6 mm, which can be treated expectantly under strict conditions including the presence of healthy bowel tissue, absence of leakage, administration of antibiotics and informed follow-up. Supported By: No support.
P-45 Morbidity associated with radical laparoscopic excision of recto-vaginal endometriosis. J. T. Wright. Ctr for Endometriosis and Pelvic Pain, Woking, UK. Objective: To audit the morbidity of radical laparoscopic excision of recto-vaginal endometriosis. It is associated with low morbidity in experienced hands (1) but is complex and associated with a steep learning curve. Realtime audit of these procedures allows rapid analysis identifying women who are at particular risk of bowel resection or urinary tract injury so that they can be appropriately counselled pre-operatively and remedial action planned as part of the procedure rather than as an emergency. The severity of disease can be classified by partial obliteration, the rectum being pulled up to the cervix but not overlying it and complete obliteration if the rectum is completely overlying the posterior pelvic cul de sac. Complete obliteration is associated with an increased likelihood of rectal sero-muscular involvement. Design: Realtime audit and review of 36 women with obliterated cul de sac disease using handheld computer technology to collect data at the time of surgery for subsequent analysis on spreadsheets and statistical packages. Materials/Methods: As above. Results: American studies (2) show that in a group of 185 patients there were nine bowel perforations (0.48%, 95% CL 0.075–2.98) and two ureteric stents (0.01% 95% CL 6.04 –2.13). 36 women with obliterated cul de sac disease were identified from the CEPP database of whom three had full thickness and 21 partial thickness rectal involvement. Partial thickness resection was repaired laparoscopically on three occasions (11% 95% CL 3.7–27.3) and vaginally on two occasions (7% 95% CL 1.8 –23.2) without morbidity, but with significant increase in operating time. Full thickness resection of the rectum was carried out on three occasions (8% 95% CL 2.64 –21.75); three patients (8% 95% CL 2.64 –21.75) required a blood transfusion. Ureteric damage occurred in two women (5% 95% CL 1.26 – 17.7). Conclusions: Ureteric damage is the only significant complication, rectal
FERTILITY & STERILITY威
resection being part of the treatment for the disease. Greater awareness that the ureter, particularly on the left side, can be caught up in the fibrotic process and become densely adherent to the recto-sigmoid means that in such cases, the ureter is dissected out from the pelvic brim to the ureteric canal to ensure its safety. 1. Redwine DB, Wright JT: Symptom relief following radical laparoscopic conservative surgery for complete obliteration of the cul de sac due to endometriosis: Fertility and Sterility 2001;76: 2:358 –365. 2. Nezhat C, Nezhat F, Pennington E. Laparoscopic treatment of infiltrative rectosigmoid colon and rectovaginal endometriosis by the technique of videolaparoscopy and the CO2 laser. Br. J. Obstet. Gyanecol. 1992;99:664 –7. Supported By: No support.
P-46 Pregnancy after surgical treatment of deep infiltrative endometriosis. E. Ferna´ ndez, C. Ferna´ ndez, R. Silva, A. Camus, S. Ferna´ ndez, A. Mackenna. Unit of Reproductive Medicine—Clin Las Condes, Santiago, Chile. Objective: Deep infiltrating endometriosis has been associated with pelvic pain and infertility. Surgical treatment of the disease restores reproductive function in infertile women. The objective of this study was to analyze pregnancy rate and time elapsed from surgery to pregnancy, in a group of infertile couples where deep infiltrative endometriosis was removed surgically. Design: Infertility work-up was performed in couples consulting for infertility of more than one year. No other important cause of infertility was found except for a deep infiltrative endometriosis observed at laparoscopy, especially at the uterosacral ligament, torus and cul de sac. Materials/Methods: Complete resection of this tissue including the disease was performed by endoscopic surgery with different levels of complexity. Histological evaluation of the tissue confirmed endometriosis. Patient follow-up was at least six months. Additional treatment such as ovarian stimulation, intrauterine insemination (IUI) and ART were performed only when necessary. Results: Three hundred and eighty patients had endometriosis with no other cause of infertility. Deep infiltrative endometriosis was found in 227 of them. One hundred and seventy-seven were surgically treated and of these, 150 were followed-up for at least 6 months. Ninety-six (74%) women became pregnant. Time elapsed between surgery and pregnancy ranged between 1 and 45 months. Forty-seven patients became pregnant spontaneously, 51% of them during the first three months. Forty-nine pregnancies were achieved after additional therapy, 8 following ovarian stimulation, 9 after stimulation and IUI and 32 after ART. Conclusions: In patients presenting deep infiltrative endometriosis resection of the disease improved reproductive function. Supported By: Unit of Reproductive Medicine—Clinica Las Condes.
P-47 Rupture of ovarian endometrioma in the midtrimester pregnancy: a case report and review of literature. S. Chii-Shinn. Chang Gung Memorial Hosp, Taipei, Taiwan. Objective: Pregnancy has beneficial effects on endometriosis is a longstanding clinical tenet. However, the relationship between endometrioma and fertility has not yet been fully clarified. Although a few cases have been reported, rupture of an ovarian endometrioma presenting as a surgical emergency during pregnancy is a rare event. Design: nil. Materials/Methods: We report a case of ruptured ovarian endometrioma during pregnancy at gestation week 28 and review those reported in literature. A 26-year-old nulliparous woman was admitted to our hospital at 28 weeks’ gestation with the chief complain of midabdominal pain. The patient had history of right adnexal mass (3.5 ⫻ 4.5 cm) with infertility of two years’ duration. Ultrasound scans performed before pregnancy revealed a right ovarian endometrioma with internal homogenous echogenecity. On the days of hospitalization, the abdominal pain became more severe and was accompanied by vomiting. The initial clinical impression was possible ruptured appendix that have been partially treated with prior antibiotic therapy. Results: At exploration of the pelvis, the abdominal cavity was found to
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P-45 Morbidity associated with radical laparoscopic excision of recto-vaginal endometriosis. J. T. Wright. Ctr for Endometriosis and Pelvic Pain, Woking, UK. Objective: To audit the morbidity of radical laparoscopic excision of recto-vaginal endometriosis. It is associated with low morbidity in experienced hands (1) but is complex and associated with a steep learning curve. Realtime audit of these procedures allows rapid analysis identifying women who are at particular risk of bowel resection or urinary tract injury so that they can be appropriately counselled pre-operatively and remedial action planned as part of the procedure rather than as an emergency. The severity of disease can be classified by partial obliteration, the rectum being pulled up to the cervix but not overlying it and complete obliteration if the rectum is completely overlying the posterior pelvic cul de sac. Complete obliteration is associated with an increased likelihood of rectal sero-muscular involvement. Design: Realtime audit and review of 36 women with obliterated cul de sac disease using handheld computer technology to collect data at the time of surgery for subsequent analysis on spreadsheets and statistical packages. Materials/Methods: As above. Results: American studies (2) show that in a group of 185 patients there were nine bowel perforations (0.48%, 95% CL 0.075–2.98) and two ureteric stents (0.01% 95% CL 6.04 –2.13). 36 women with obliterated cul de sac disease were identified from the CEPP database of whom three had full thickness and 21 partial thickness rectal involvement. Partial thickness resection was repaired laparoscopically on three occasions (11% 95% CL 3.7–27.3) and vaginally on two occasions (7% 95% CL 1.8 –23.2) without morbidity, but with significant increase in operating time. Full thickness resection of the rectum was carried out on three occasions (8% 95% CL 2.64 –21.75); three patients (8% 95% CL 2.64 –21.75) required a blood transfusion. Ureteric damage occurred in two women (5% 95% CL 1.26 – 17.7). Conclusions: Ureteric damage is the only significant complication, rectal
FERTILITY & STERILITY威
resection being part of the treatment for the disease. Greater awareness that the ureter, particularly on the left side, can be caught up in the fibrotic process and become densely adherent to the recto-sigmoid means that in such cases, the ureter is dissected out from the pelvic brim to the ureteric canal to ensure its safety. 1. Redwine DB, Wright JT: Symptom relief following radical laparoscopic conservative surgery for complete obliteration of the cul de sac due to endometriosis: Fertility and Sterility 2001;76: 2:358 –365. 2. Nezhat C, Nezhat F, Pennington E. Laparoscopic treatment of infiltrative rectosigmoid colon and rectovaginal endometriosis by the technique of videolaparoscopy and the CO2 laser. Br. J. Obstet. Gyanecol. 1992;99:664 –7. Supported By: No support.
P-46 Pregnancy after surgical treatment of deep infiltrative endometriosis. E. Ferna´ ndez, C. Ferna´ ndez, R. Silva, A. Camus, S. Ferna´ ndez, A. Mackenna. Unit of Reproductive Medicine—Clin Las Condes, Santiago, Chile. Objective: Deep infiltrating endometriosis has been associated with pelvic pain and infertility. Surgical treatment of the disease restores reproductive function in infertile women. The objective of this study was to analyze pregnancy rate and time elapsed from surgery to pregnancy, in a group of infertile couples where deep infiltrative endometriosis was removed surgically. Design: Infertility work-up was performed in couples consulting for infertility of more than one year. No other important cause of infertility was found except for a deep infiltrative endometriosis observed at laparoscopy, especially at the uterosacral ligament, torus and cul de sac. Materials/Methods: Complete resection of this tissue including the disease was performed by endoscopic surgery with different levels of complexity. Histological evaluation of the tissue confirmed endometriosis. Patient follow-up was at least six months. Additional treatment such as ovarian stimulation, intrauterine insemination (IUI) and ART were performed only when necessary. Results: Three hundred and eighty patients had endometriosis with no other cause of infertility. Deep infiltrative endometriosis was found in 227 of them. One hundred and seventy-seven were surgically treated and of these, 150 were followed-up for at least 6 months. Ninety-six (74%) women became pregnant. Time elapsed between surgery and pregnancy ranged between 1 and 45 months. Forty-seven patients became pregnant spontaneously, 51% of them during the first three months. Forty-nine pregnancies were achieved after additional therapy, 8 following ovarian stimulation, 9 after stimulation and IUI and 32 after ART. Conclusions: In patients presenting deep infiltrative endometriosis resection of the disease improved reproductive function. Supported By: Unit of Reproductive Medicine—Clinica Las Condes.
P-47 Rupture of ovarian endometrioma in the midtrimester pregnancy: a case report and review of literature. S. Chii-Shinn. Chang Gung Memorial Hosp, Taipei, Taiwan. Objective: Pregnancy has beneficial effects on endometriosis is a longstanding clinical tenet. However, the relationship between endometrioma and fertility has not yet been fully clarified. Although a few cases have been reported, rupture of an ovarian endometrioma presenting as a surgical emergency during pregnancy is a rare event. Design: nil. Materials/Methods: We report a case of ruptured ovarian endometrioma during pregnancy at gestation week 28 and review those reported in literature. A 26-year-old nulliparous woman was admitted to our hospital at 28 weeks’ gestation with the chief complain of midabdominal pain. The patient had history of right adnexal mass (3.5 ⫻ 4.5 cm) with infertility of two years’ duration. Ultrasound scans performed before pregnancy revealed a right ovarian endometrioma with internal homogenous echogenecity. On the days of hospitalization, the abdominal pain became more severe and was accompanied by vomiting. The initial clinical impression was possible ruptured appendix that have been partially treated with prior antibiotic therapy. Results: At exploration of the pelvis, the abdominal cavity was found to
S39