- Email: [email protected]
Swimming Against the Stream: Is Surgery Worthwhile in Women with Deep Infiltrating Endometriosis and Pregnancy Intention?
Accepted Manuscript Title: Swimming Against the Stream: is Surgery Worthwhile in Women with Deep Infiltrating Endometriosis and Pregnancy Intention? Author: Basma Darwish, Isabella Chanavaz-Lacheray, Horace Roman PII: DOI: Reference:
S1553-4650(17)31095-6 http://dx.doi.org/doi: 10.1016/j.jmig.2017.07.028 JMIG 3256
To appear in:
The Journal of Minimally Invasive Gynecology
Please cite this article as: Basma Darwish, Isabella Chanavaz-Lacheray, Horace Roman, Swimming Against the Stream: is Surgery Worthwhile in Women with Deep Infiltrating Endometriosis and Pregnancy Intention?, The Journal of Minimally Invasive Gynecology (2017), http://dx.doi.org/doi: 10.1016/j.jmig.2017.07.028. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
1
Perspective
2
Swimming Against the Stream: Is Surgery Worthwhile in Women With Deep Infiltrating
3
Endometriosis and Pregnancy Intention?
4
Basma Darwish, MD, Isabella Chanavaz-Lacheray, MD, Horace Roman, MD, PhD*
5
From the Expert Center in Diagnostic and Management of Endometriosis, Department of
6
Gynecology and Obstetrics (Drs Darwish, Chanavaz-Lacheray, and Roman); Assisted
7
Reproductive Medicine Department (Dr Chanavaz-Lacheray), and Research Group 4308
8
Spermatogenesis and Gamete Quality, Rouen University Hospital, Rouen, France (Dr Roman).
9
*Corresponding author: Horace Roman, MD, PhD, Clinique Gynécologique et Obstétricale, CHU
10
Charles Nicolle, 1 rue de Germont, 76031 Rouen, France, Telephone: 332 328 887 54; Facsimile:
11
332 359 811 49; E-mail: [email protected]
12
Conflict of interest: Prof. Roman reports personal fees from Plasma Surgical Inc. (Roswell,
13
Georgia) for participating in a symposium and a masterclass, in which he presented his
14
experience in the use of plasma energy. Other authors have no conflicts of interest.
Comment [A1]: AUTHOR: Article Title has two versions. Please check if the Article Title used is correct.
15
16
17
1
Page 1 of 10
18
Optimal management such as surgery versus assisted reproductive techniques (ART) for
19
patients with severe endometriosis who desire pregnancy is strongly debated. The absence of
20
randomized trials comparing primary surgery with first-line in vitro fertilization (IVF) leaves
21
room for individualized interpretation of available studies, most of which are non-comparative,
22
retrospective cohorts.
23
The European Society of Human Reproduction and Embryology (ESHRE) has released its latest
24
recommendations, regardless of the absence of studies with a high level of evidence [1]. For
25
infertile women with deep endometriosis, there is no evidence to support performing surgical
26
excision of deep nodular lesions prior to ART to improve reproductive outcomes. However,
27
because women with deep infiltrating endometriosis often suffer from pain, patients typically
28
request surgical treatment creating a challenging management conundrum for physicians [1].
29
In the absence of randomized trials, the release of such recommendations is justified. However,
30
there is not always consensus. There are no data stating that women with severe deep
31
endometriosis with pregnancy intention require IVF as first-line treatment. Although the
32
benefits of deep infiltrating endometriosis surgery on the outcomes of IVF have not been
33
clearly demonstrated, it is likely that surgery has a potential beneficial impact on spontaneous
34
pregnancy [2-6].
35
It is not known whether infertile women with deep infiltrating endometriosis are always
36
infertile after surgery. Although ovarian cystectomy for endometriomas can reduce ovarian
37
reserve and therefore alter IVF results, there is no evidence that surgery for deep
38
endometriosis has a negative impact on ovarian reserve. On the other hand, the ESHRE
2
Page 2 of 10
39
recommendations unfortunately do not advise of complications that patients with deep
40
endometriosis could sustain during IVF stimulation, specifically in cases where the disease has
41
not been treated initially by surgery.
42
It may be easier for many women with severe deep infiltrating endometriosis to turn to IVF
43
initially owing to a greater presence of IVF centers versus multidisciplinary endometriosis
44
centers as well as full reimbursement of IVF cycles in several countries. Typically, physicians
45
offer young women the choice between pregnancy by ART versus symptom improvement
46
achieved by surgery. However, choosing treatment suggests that both goals cannot be achieved
47
simultaneously. Young women fearful of never being able to conceive might choose pregnancy
48
as first priority. A typical scenario begins with a young woman who upon discontinuing her
49
contraceptive pill unmasks painful symptoms related to deep infiltrating intestinal
50
endometriosis and is therefore offered first-line IVF treatment. In the best conditions, she will
51
benefit from IVF early in treatment. When treatment fails, which statistically occurs in more
52
than two-thirds of cases, a second IVF cycle will be scheduled after a few months.
53
In patients with deep infiltrating endometriosis, the most optimistic pregnancy rate reported
54
was a cumulative overall pregnancy rate of 68% after 3 consecutive IVF cycles [7]. Without
55
breaking between IVF cycles, the best scenario for patients is minimal pain increase and either
56
disease stabilization or minimal lesion growth. However, this optimistic scenario is far from
57
being a rule.
58
In September 2015, we reported a series of 12 patients managed for occlusive and subocclusive
59
deep infiltrating colorectal endometriosis [8]. Patients were advised to postpone surgery until
3
Page 3 of 10
60
after pregnancy, which inevitably led to severe symptoms of bowel stenosis [8]. The patients
61
enrolled in the study represented 5% of the total 241 patients managed from January 2012 to
62
January 2015 in our center.
63
Among 69 women managed for deep endometriosis resulting in stenosis of ureters since June
64
2009, 8 patients have concomitantly been treated for infertility in another facility (11.6%). All 8
65
women had grade 3/4 hydronephrosis, while 2 had mute kidneys (unpublished data). In all
66
patients, deep infiltrating endometriosis had been diagnosed several months or years before,
67
but first-line IVF was initially recommended. Meanwhile patients remained symptomatic during
68
the ART management to the extent that all of them required the insertion of double J stents for
69
months or years; however surgical removal of deep endometriosis was systematically
70
postponed. [2–4]
71
From January 2016 to February 2017, 22 women were managed at our center for deep
72
endometriosis compressing (19 cases) or infiltrating (3 cases) the sacral roots (unpublished
73
data). Thirteen (59%) were intending to get pregnant and were advised to postpone surgery
74
until after first-line IVF. However, they were symptomatic and sought care in our department to
75
treat their symptoms against the council of physicians managing their infertility.
76
Do these women merely represent rare cases, which are incidentally over-represented in our
77
database? Or is it more likely that they are under-evaluated in the literature, especially because
78
the majority of journals prefer not to publish case reports owing to the impact factor.
79
Therefore, prospective databases in reference centers are an indispensable source of rare
80
events and important clinical information.
4
Page 4 of 10
81
The risk of severe complications following surgery for deep infiltrating endometriosis, such as
82
rectovaginal fistulae, bladder atony, and digestive functional sequelae is well known and can be
83
perceived as an unpredictable or inevitable fate, although in reality is far from being true. For
84
experienced surgical teams, the risk of complications is lower and the frequency of rectovaginal
85
fistulae is close to 3%, but repaired without sequelae in the majority of cases [9]. Deep pelvic
86
abscesses occur in about 5% of cases, but can be drained without consequences, provided they
87
are identified without delay. Surgery for deep infiltrating endometriosis can be performed
88
laparoscopically in more than 90% of cases, considerably reducing the risk of adhesions,
89
postoperative pain, duration of convalescence, and allows for spontaneous conception [9]. The
90
risk of digestive dysfunction is linked to the stage of the disease, thus the deliberate delay in
91
surgical management may lead to the raise of complications and sequelae rates.
92
The larger the rectal nodule, the less feasible it is to preserve the rectum by shaving or discoid
93
excision, and the risk of colorectal resection is higher, leading to a higher rate of subsequent
94
functional sequelae. Moreover, the greater the vaginal infiltration, the greater the risk of
95
splanchnic nerve dysfunction and postoperative bladder atony. The surgeon who performs an
96
extensive rectal, bladder, vaginal, and ureteral resection will only regret not having carried out
97
the procedure years earlier, when less-aggressive surgical techniques and less morbidity were
98
more probable.
99
The low risk of severe postoperative complications should be weighed against the positive
100
results in terms of postoperative fertility [10]. For patients with deep infiltrating endometriosis,
101
postoperative pregnancy rates are at least as good as those reported after first-line IVF [2-6]. In
5
Page 5 of 10
102
our database, 65% of patients operated for associated colorectal endometriosis and ovarian
103
endometriomas were pregnant after surgery, and it is estimated that about 74.5% of
104
pregnancies occurred during the first 3 postoperative years [11]. In addition, 60% of
105
postoperative pregnancies were spontaneous [11]. Therefore, the two objectives of care
106
(achieving pregnancy and improving pain) can be simultaneously achieved by first-line surgical
107
treatment. Estimated spontaneous postoperative pregnancy rates attributable to surgery for
108
deep infiltrating endometriosis averages 25% [6,12], implying that first-line surgical
109
management can reasonably be offered to women with deep endometriosis and desire for
110
pregnancy.
111
There is certainly no single path to follow, but management may be determined by several
112
factors: severity of endometriosis infiltration, risks of disease evolution that determines the
113
type of surgery, time until menopause owing to risk of recurrence, ovarian reserve, the
114
possibility of restoring tubal permeability, spermatic parameters of the spouse, severity of
115
symptoms. It is important to modify management with a long-term approach determined by
116
the association of the above-mentioned factors that lead to the complexity of reasoning and
117
expertise required to make an appropriate decision. For example, first line surgical treatment
118
has its place in the management of patients with deep infiltrating endometriosis associated
119
with bilateral ovarian endometriomas and a reduced ovarian reserve [13]. Indeed, it is in those
120
patients with a low ovarian reserve that the response to controlled stimulation in IVF is poor
121
and that several stimulation cycles are needed; furthermore, unsuccessful procedures may lead
122
to the patient abandoning reproductive assistance. On the other hand, women with a low
123
ovarian reserve retain their chances to spontaneous conception, and it is precisely these cases
6
Page 6 of 10
124
that surgery can allow for a spontaneous conception [13]. In cases of rectal or ureteral deep
125
endometriosis with associated endometriomas and altered ovarian reserve, the option of
126
surgery of deep lesions without concomitant curative treatment of the ovaries can be a solution
127
without negative impact on future IVF, but with an immediate improvement in pelvic comfort
128
and quality of life. In addition, several authors observed an improvement in IVF pregnancy rates
129
in patients surgically managed for deep rectovaginal endometriosis with [3,4] or without [2]
130
infiltration of the digestive tract. Their reports suggest that, far from being harmful, surgery for
131
deep endometriosis may be beneficial when it precedes ART.
132
The aim of this editorial is not to plead for first-line surgery in all women with deep
133
endometriosis and pregnancy intention. We defend the principles of conservative surgery to
134
reduce the risk of postoperative complications and functional sequelae. Conservative surgery,
135
being performed in the majority of our patients with deep endometriosis infiltrating the bowel
136
[14] and ureters [15] results in high postoperative pregnancy rates, the majority of which are
137
the result of spontaneous conception, as well as a low complication rate. Reduction of health
138
expenditure needs to be demonstrated. Nevertheless, delay in surgical management reduces
139
the feasibility of conservative surgery, particularly in diseases that evolve and result in bowel
140
obstruction, ureteral stenosis, or irreversible renal atrophy. When this delay is the result of a
141
questionable management strategy for infertility based on a fragile scientific basis, the
142
questioning of such a strategy is not only a right, but rather a duty.
143
7
Page 7 of 10
144
References
145
1. Dunselman GA, Vermeulen N, Becker C, et al. ESHRE guideline: management of women with
146
endometriosis. Hum Reprod. 2014;29:400–412.
147
2. Bianchi PH, Pereira RM, Zanatta A, Alegretti JR, Motta EL, Serafini PC. Extensive excision of
148
deep infiltrative endometriosis before in vitro fertilization significantly improves pregnancy
149
rates. J Minim Invasive Gynecol. 2009;16:174–180.
150
3. Ballester M, Roman H, Mathieu E, Touleimat S, Belghiti J, Darai E. Prior colorectal surgery for
151
endometrosis-associated infertility improves ICSI-IVF outcomes: results from two expert
152
centres. Eur J Obstet Gynecol Reprod Biol. 2017;209:95–99.
153
4. Bendifallah S, Roman H, Mathieu d’Argent E, et al. Colorectal endometriosis-associated
154
infertility: should surgery precede ART? Fertil Steril. 2017; In press.
155
5. Iversen ML, Seyer-Hansen M, Forman A. Does surgery for deep infiltrating bowel
156
endometriosis improve fertility? A systematic review. Acta Obstet Gynecol Scand. 2017;96:688–
157
693.
158
6. Cohen J, Thomin A, Mathieu d’Argent E, et al. Fertility before and after surgery for deep
159
infiltrating endometriosis with and without bowel involvement: a literature review. Minerva
160
Ginecol. 2014;66:575–587.
161
7. Ballester M, Mathieu d’Argent E, Morcel K, Belaisch-Allart J, Nisolle M, Daraı E. Cumulative
162
pregnancy rate after ICSI-IVF in patients with colorectal endometriosis: results of a multicentre
163
study. Hum Reprod. 2012;27:1043–1049.
8
Page 8 of 10
164
8. Roman H, Puscasiu L, Lempicki M, et al. Colorectal endometriosis responsible for bowel
165
occlusion or subocclusion in women with pregnancy intention: is the policy of primary in vitro
166
fertilization always safe? J Minim Invasive Gynecol. 2015;22:1059–1067.
167
9. Roman H; FRIENDS group (French coloRectal Infiltrating ENDometriosis Study group). A
168
national snapshot of the surgical management of deep infiltrating endometriosis of the rectum
169
and colon in France in 2015: A multicenter series of 1135 cases. J Gynecol Obstet Hum Reprod.
170
2017;46:159–165.
171
10. Roman H. Colorectal endometriosis and pregnancy wish: why doing primary surgery. Front
172
Biosci (Schol Ed). 2015;7:83–93.
173
11. Roman H, Quibel S, Auber M, et al. Recurrences and fertility after endometrioma ablation in
174
women with and without colorectal endometriosis: a prospective cohort study. Hum Reprod.
175
2015;30:558–568.
176
12. Berlanda N, Vercellini P, Somigliana E, Frattaruolo MP, Buggio L, Gattei U. Role of surgery in
177
endometriosis-associated subfertility. Semin Reprod Med. 2013;31:133–143.
178
13. Stochino-Loi E, Darwish B, Mircea O, et al. Does preoperative antimüllerian hormone level
179
influence postoperative pregnancy rate in women undergoing surgery for severe
180
endometriosis? Fertil Steril. 2017;107:707.e3–713.e3.
181
14. Roman H, Darwish B, Bridoux V, et al. Functional outcomes after disc excision in deep
182
endometriosis of the rectum using transanal staplers: a series of 111 consecutive patients. Fertil
183
Steril. 2017;107:977–986.
9
Page 9 of 10
184
15. Darwish B, Stochino-Loi E, Pasquier G, et al. Surgical outcomes of urinary tract deep
185
infiltrating endometriosis. J Minim Invasive Gynecol. 2017; In press.
186
10
Page 10 of 10
S1553-4650(17)31095-6 http://dx.doi.org/doi: 10.1016/j.jmig.2017.07.028 JMIG 3256
To appear in:
The Journal of Minimally Invasive Gynecology
Please cite this article as: Basma Darwish, Isabella Chanavaz-Lacheray, Horace Roman, Swimming Against the Stream: is Surgery Worthwhile in Women with Deep Infiltrating Endometriosis and Pregnancy Intention?, The Journal of Minimally Invasive Gynecology (2017), http://dx.doi.org/doi: 10.1016/j.jmig.2017.07.028. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
1
Perspective
2
Swimming Against the Stream: Is Surgery Worthwhile in Women With Deep Infiltrating
3
Endometriosis and Pregnancy Intention?
4
Basma Darwish, MD, Isabella Chanavaz-Lacheray, MD, Horace Roman, MD, PhD*
5
From the Expert Center in Diagnostic and Management of Endometriosis, Department of
6
Gynecology and Obstetrics (Drs Darwish, Chanavaz-Lacheray, and Roman); Assisted
7
Reproductive Medicine Department (Dr Chanavaz-Lacheray), and Research Group 4308
8
Spermatogenesis and Gamete Quality, Rouen University Hospital, Rouen, France (Dr Roman).
9
*Corresponding author: Horace Roman, MD, PhD, Clinique Gynécologique et Obstétricale, CHU
10
Charles Nicolle, 1 rue de Germont, 76031 Rouen, France, Telephone: 332 328 887 54; Facsimile:
11
332 359 811 49; E-mail: [email protected]
12
Conflict of interest: Prof. Roman reports personal fees from Plasma Surgical Inc. (Roswell,
13
Georgia) for participating in a symposium and a masterclass, in which he presented his
14
experience in the use of plasma energy. Other authors have no conflicts of interest.
Comment [A1]: AUTHOR: Article Title has two versions. Please check if the Article Title used is correct.
15
16
17
1
Page 1 of 10
18
Optimal management such as surgery versus assisted reproductive techniques (ART) for
19
patients with severe endometriosis who desire pregnancy is strongly debated. The absence of
20
randomized trials comparing primary surgery with first-line in vitro fertilization (IVF) leaves
21
room for individualized interpretation of available studies, most of which are non-comparative,
22
retrospective cohorts.
23
The European Society of Human Reproduction and Embryology (ESHRE) has released its latest
24
recommendations, regardless of the absence of studies with a high level of evidence [1]. For
25
infertile women with deep endometriosis, there is no evidence to support performing surgical
26
excision of deep nodular lesions prior to ART to improve reproductive outcomes. However,
27
because women with deep infiltrating endometriosis often suffer from pain, patients typically
28
request surgical treatment creating a challenging management conundrum for physicians [1].
29
In the absence of randomized trials, the release of such recommendations is justified. However,
30
there is not always consensus. There are no data stating that women with severe deep
31
endometriosis with pregnancy intention require IVF as first-line treatment. Although the
32
benefits of deep infiltrating endometriosis surgery on the outcomes of IVF have not been
33
clearly demonstrated, it is likely that surgery has a potential beneficial impact on spontaneous
34
pregnancy [2-6].
35
It is not known whether infertile women with deep infiltrating endometriosis are always
36
infertile after surgery. Although ovarian cystectomy for endometriomas can reduce ovarian
37
reserve and therefore alter IVF results, there is no evidence that surgery for deep
38
endometriosis has a negative impact on ovarian reserve. On the other hand, the ESHRE
2
Page 2 of 10
39
recommendations unfortunately do not advise of complications that patients with deep
40
endometriosis could sustain during IVF stimulation, specifically in cases where the disease has
41
not been treated initially by surgery.
42
It may be easier for many women with severe deep infiltrating endometriosis to turn to IVF
43
initially owing to a greater presence of IVF centers versus multidisciplinary endometriosis
44
centers as well as full reimbursement of IVF cycles in several countries. Typically, physicians
45
offer young women the choice between pregnancy by ART versus symptom improvement
46
achieved by surgery. However, choosing treatment suggests that both goals cannot be achieved
47
simultaneously. Young women fearful of never being able to conceive might choose pregnancy
48
as first priority. A typical scenario begins with a young woman who upon discontinuing her
49
contraceptive pill unmasks painful symptoms related to deep infiltrating intestinal
50
endometriosis and is therefore offered first-line IVF treatment. In the best conditions, she will
51
benefit from IVF early in treatment. When treatment fails, which statistically occurs in more
52
than two-thirds of cases, a second IVF cycle will be scheduled after a few months.
53
In patients with deep infiltrating endometriosis, the most optimistic pregnancy rate reported
54
was a cumulative overall pregnancy rate of 68% after 3 consecutive IVF cycles [7]. Without
55
breaking between IVF cycles, the best scenario for patients is minimal pain increase and either
56
disease stabilization or minimal lesion growth. However, this optimistic scenario is far from
57
being a rule.
58
In September 2015, we reported a series of 12 patients managed for occlusive and subocclusive
59
deep infiltrating colorectal endometriosis [8]. Patients were advised to postpone surgery until
3
Page 3 of 10
60
after pregnancy, which inevitably led to severe symptoms of bowel stenosis [8]. The patients
61
enrolled in the study represented 5% of the total 241 patients managed from January 2012 to
62
January 2015 in our center.
63
Among 69 women managed for deep endometriosis resulting in stenosis of ureters since June
64
2009, 8 patients have concomitantly been treated for infertility in another facility (11.6%). All 8
65
women had grade 3/4 hydronephrosis, while 2 had mute kidneys (unpublished data). In all
66
patients, deep infiltrating endometriosis had been diagnosed several months or years before,
67
but first-line IVF was initially recommended. Meanwhile patients remained symptomatic during
68
the ART management to the extent that all of them required the insertion of double J stents for
69
months or years; however surgical removal of deep endometriosis was systematically
70
postponed. [2–4]
71
From January 2016 to February 2017, 22 women were managed at our center for deep
72
endometriosis compressing (19 cases) or infiltrating (3 cases) the sacral roots (unpublished
73
data). Thirteen (59%) were intending to get pregnant and were advised to postpone surgery
74
until after first-line IVF. However, they were symptomatic and sought care in our department to
75
treat their symptoms against the council of physicians managing their infertility.
76
Do these women merely represent rare cases, which are incidentally over-represented in our
77
database? Or is it more likely that they are under-evaluated in the literature, especially because
78
the majority of journals prefer not to publish case reports owing to the impact factor.
79
Therefore, prospective databases in reference centers are an indispensable source of rare
80
events and important clinical information.
4
Page 4 of 10
81
The risk of severe complications following surgery for deep infiltrating endometriosis, such as
82
rectovaginal fistulae, bladder atony, and digestive functional sequelae is well known and can be
83
perceived as an unpredictable or inevitable fate, although in reality is far from being true. For
84
experienced surgical teams, the risk of complications is lower and the frequency of rectovaginal
85
fistulae is close to 3%, but repaired without sequelae in the majority of cases [9]. Deep pelvic
86
abscesses occur in about 5% of cases, but can be drained without consequences, provided they
87
are identified without delay. Surgery for deep infiltrating endometriosis can be performed
88
laparoscopically in more than 90% of cases, considerably reducing the risk of adhesions,
89
postoperative pain, duration of convalescence, and allows for spontaneous conception [9]. The
90
risk of digestive dysfunction is linked to the stage of the disease, thus the deliberate delay in
91
surgical management may lead to the raise of complications and sequelae rates.
92
The larger the rectal nodule, the less feasible it is to preserve the rectum by shaving or discoid
93
excision, and the risk of colorectal resection is higher, leading to a higher rate of subsequent
94
functional sequelae. Moreover, the greater the vaginal infiltration, the greater the risk of
95
splanchnic nerve dysfunction and postoperative bladder atony. The surgeon who performs an
96
extensive rectal, bladder, vaginal, and ureteral resection will only regret not having carried out
97
the procedure years earlier, when less-aggressive surgical techniques and less morbidity were
98
more probable.
99
The low risk of severe postoperative complications should be weighed against the positive
100
results in terms of postoperative fertility [10]. For patients with deep infiltrating endometriosis,
101
postoperative pregnancy rates are at least as good as those reported after first-line IVF [2-6]. In
5
Page 5 of 10
102
our database, 65% of patients operated for associated colorectal endometriosis and ovarian
103
endometriomas were pregnant after surgery, and it is estimated that about 74.5% of
104
pregnancies occurred during the first 3 postoperative years [11]. In addition, 60% of
105
postoperative pregnancies were spontaneous [11]. Therefore, the two objectives of care
106
(achieving pregnancy and improving pain) can be simultaneously achieved by first-line surgical
107
treatment. Estimated spontaneous postoperative pregnancy rates attributable to surgery for
108
deep infiltrating endometriosis averages 25% [6,12], implying that first-line surgical
109
management can reasonably be offered to women with deep endometriosis and desire for
110
pregnancy.
111
There is certainly no single path to follow, but management may be determined by several
112
factors: severity of endometriosis infiltration, risks of disease evolution that determines the
113
type of surgery, time until menopause owing to risk of recurrence, ovarian reserve, the
114
possibility of restoring tubal permeability, spermatic parameters of the spouse, severity of
115
symptoms. It is important to modify management with a long-term approach determined by
116
the association of the above-mentioned factors that lead to the complexity of reasoning and
117
expertise required to make an appropriate decision. For example, first line surgical treatment
118
has its place in the management of patients with deep infiltrating endometriosis associated
119
with bilateral ovarian endometriomas and a reduced ovarian reserve [13]. Indeed, it is in those
120
patients with a low ovarian reserve that the response to controlled stimulation in IVF is poor
121
and that several stimulation cycles are needed; furthermore, unsuccessful procedures may lead
122
to the patient abandoning reproductive assistance. On the other hand, women with a low
123
ovarian reserve retain their chances to spontaneous conception, and it is precisely these cases
6
Page 6 of 10
124
that surgery can allow for a spontaneous conception [13]. In cases of rectal or ureteral deep
125
endometriosis with associated endometriomas and altered ovarian reserve, the option of
126
surgery of deep lesions without concomitant curative treatment of the ovaries can be a solution
127
without negative impact on future IVF, but with an immediate improvement in pelvic comfort
128
and quality of life. In addition, several authors observed an improvement in IVF pregnancy rates
129
in patients surgically managed for deep rectovaginal endometriosis with [3,4] or without [2]
130
infiltration of the digestive tract. Their reports suggest that, far from being harmful, surgery for
131
deep endometriosis may be beneficial when it precedes ART.
132
The aim of this editorial is not to plead for first-line surgery in all women with deep
133
endometriosis and pregnancy intention. We defend the principles of conservative surgery to
134
reduce the risk of postoperative complications and functional sequelae. Conservative surgery,
135
being performed in the majority of our patients with deep endometriosis infiltrating the bowel
136
[14] and ureters [15] results in high postoperative pregnancy rates, the majority of which are
137
the result of spontaneous conception, as well as a low complication rate. Reduction of health
138
expenditure needs to be demonstrated. Nevertheless, delay in surgical management reduces
139
the feasibility of conservative surgery, particularly in diseases that evolve and result in bowel
140
obstruction, ureteral stenosis, or irreversible renal atrophy. When this delay is the result of a
141
questionable management strategy for infertility based on a fragile scientific basis, the
142
questioning of such a strategy is not only a right, but rather a duty.
143
7
Page 7 of 10
144
References
145
1. Dunselman GA, Vermeulen N, Becker C, et al. ESHRE guideline: management of women with
146
endometriosis. Hum Reprod. 2014;29:400–412.
147
2. Bianchi PH, Pereira RM, Zanatta A, Alegretti JR, Motta EL, Serafini PC. Extensive excision of
148
deep infiltrative endometriosis before in vitro fertilization significantly improves pregnancy
149
rates. J Minim Invasive Gynecol. 2009;16:174–180.
150
3. Ballester M, Roman H, Mathieu E, Touleimat S, Belghiti J, Darai E. Prior colorectal surgery for
151
endometrosis-associated infertility improves ICSI-IVF outcomes: results from two expert
152
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