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Ultrasound-guided aspiration of endometriomas: possible applications and limitations
Vol. 64, No.4, October 1995
FERTILITY AND STERILITY Copyright
~")
1995 American Society for Reproductive Medicine
Printed on acid·free paper in U. S. A.
Ultrasound-guided aspiration of endometriomas: possible applications and limitations
Gerardo Zanetta, M.D.* Andrea Lissoni, M.D. Cristina Dalla Valle, M.D.
Diego Trio, M.D. Mariarosa Pittelli, M.D. Giovanni Rangoni, M.D.
Department of Obstetrics and Gynecology, San Gerardo Hospital, Monza, III Branch of the University of Milan, Monza Italy
Objectives: To evaluate the role of needle aspiration in the management of endometriomas. Design: Retrospective evaluation of the activity of the section of interventional ultrasound in a single tertiary care institution. Setting: Department of Obstetrics and Gynecology, Ospedale S. Gerardo, Monza, University of Milan, Italy. Patients: Two hundred nine premenopausal patients underwent aspiration for diagnostic purpose (n = 166), for relief of symptoms (n = 25), or with therapeutic intent (n = 18). Results: Adequate material was obtained by all punctures. Early complications (self-limiting vagal symptoms or pain) occurred in eight cases. Short-term complications consisted of acute abdominal pain in three cases and infection in one. Three women required surgical treatment of the complication. At first examination after aspiration, persistence of the cyst was observed in all but four cases, including all cases who had undergone therapeutic aspiration. Nine patients reported relief of symptoms but six other patients referred onset or worsening of pelvic discomfort after aspiration. Conclusions: Ultrasound-guided aspiration of endometriomas is feasible. The transvaginal route reduces early complication but implies a risk of infection of 1.3%. However, drainage alone is ineffective as a therapeutic procedure and the applications of aspiration of endometriomas appear limited to some cases with diagnostic intent. Fertil Steril 1995;64:709-13 Key Words: Ultrasound, endometriomas, endometriosis, fine-needle aspiration, interventional ultrasound
Endometriosis represents one of the leading causes of hospitalization for gynecological reasons among women in western countries and is one of the most important causes of morbidity and sterility among women of fertile age (1, 2). Although several lesions may be detected only by laparoscopy or laparotomy, a relevant part of endometriotic lesions is represented by palpable cystic masses involving the ovary and/or the fallopian tube. Sonographic features such as thick hypoechoic content, thick capsule, and presence of aggregations allow the diagnosis or the suspicion of endometrioma in the majority of cases (3, 4). The option of puncturing cystic adnexal masses with diagnostic or theraReceived January 10, 1995; revised and accepted April 20, 1995. * Reprint requests: Gerardo Zanetta, M.D., Divisione Ostetricia Ginecologia Ospedale San Gerardo, Via Solferino 16 20052 Monza, Italy (FAX: 39-39-2333820). Vol. 64, No.4, October 1995
peutic purpose has been considered by some authors (5-8) and has proved to be feasible technically (9).
This option remains controversial because of the feared risk of spreading neoplastic cells in case of unsuspected malignancy (10), but this risk is extremely low in young women with endometriomas. Progression of endometriomas to malignancy is negligible at a young age and occurs in a minority of patients in perimenopausal age (11). Few studies specifically address the possible usefulness of fine-needle aspiration of endometriomas (12-15). In the past the aspiration has been proposed for diagnostic purpose (9), to confirm cases with uncertain symptoms and/or sonographic findings before further surgical or medical treatments. It also has been proposed for relief of symptoms (13) in women undergoing medical treatment or as a preliminary step before induction of ovulation in IVF programs (14, 16). Finally, this procedure has been Zan etta et al. Aspiration of endometriomas
709
proposed as one step of a therapeutic approach that includes aspiration with or without medical treatment afterward (8, 13, 15, 17). In this paper we review our recent experience with puncture of endometriomas under ultrasound (US) guidance. MATERIALS AND METHODS
From January 1986 to December 1994, 209 patients with ovarian endometriomas underwent USguided puncture and aspiration at our service of interventional US. Patients ranged in age from 19 to 50 years (mean 34 years; median 34 years). The diagnosis of endometriosis was based upon a combination of clinical signs, macroscopic characters of the aspirated fluid, and cytologic examination. All cysts had macroscopic "chocolate" content at aspiration. The observation of endometrial cells at cytologic examination was considered sufficient for diagnosis and was recorded in 72 cases. In the remaining 137 cases, only macrophages containing hemosiderin were observed in cystic masses that had remained unchanged for 20:3 months before aspiration and were accompanied by clinical signs or symptoms of endometriosis. This second parameter for diagnosis was chosen as it is known that several old endometriomas lack an epithelial lining. The risk of misinterpreting hemorrhagic or luteal cysts appears very low in cases with unchanged morphology for several months and with clinical signs of endometriosis. Patients had been referred for differential diagnosis of endometriotic versus other cystic masses (166 patients), for temporary relief of symptoms during medical treatment of endometriosis (25 patients), and for complete aspiration as a step of a treatment with or without subsequent administration of GnRH agonists (GnRH-a) (18 patients). Ultrasound examination was performed with real time instruments (SS90A, Toshiba, Tokyo, Japan; AU 450 and 540A, Ansaldo, Genua, Italy). A 3.5 MHz transabdominal and a 6.5 MHz transvaginal probe was used. From 1986 to 1989, all patients underwent transabdominal US because of the unavailability of transvaginal probes. Since 1990, transvaginal probes were available and used increasingly. In the last 3 years, transvaginal examination was essential for the definition of the character of the cyst before any further diagnostic approach. Eligibility criteria for puncture were absence of vegetation or papillations, not more than three thin «3 mm thick) septa, and absence of free fluid in the pouch of Douglas. The diameter of the cysts ranged from 10 to 90 mm (mean 55 mm, median 48 mm). All procedures took place on an outpatient basis. One hundred 710
Zanetta et al. Aspiration of endometriomas
thirty-five punctures were performed transabdominally and 74 were performed transvaginally. In both cases no anesthesia nor sedation was used and preparation of the abdomen or vagina was performed with povidone iodide. All instruments used were sterile and disposable, with the exception of reusable plastic guides for the needles and aspiration handles. Chiba needles (Hakko Shoji, Tokyo, Japan) ranging from 17.5 to 19 gauge were used for aspiration of the content. The 17.5-gauge needles were used in 98 procedures, 18 gauge were used in 23, and 19 gauge were used in the remaining 88. Antibiotics were not prescribed routinely in cases of simple diagnostic aspiration but were prescribed after "therapeutic" aspiration or in cases of technically difficult procedures requiring prolonged aspiration time or repeated punctures. A few milliliters of fluid were collected in diagnostic procedures, whereas the cyst was drained completely in the remaining cases. Lavage of the cyst was never attempted. The aspirated fluid always was fixed in 3.8% sodium citrate and was forwarded for cytologic examination. Despite the known limitations of cytologic examination of cystic fluid, it was standard policy to confirm microscopically the macroscopic diagnosis and to exclude the presence of cellular atypia or malignant cells. Early complications were defined as those occurring in the first 24 hours (in the vast majority of cases within a few minutes) after the procedure. Short-term complications were defined as those occurring in the first 5 days after the puncture, according to criteria described in a previous study (9). All patients were scheduled for a second scan 2 to 3 months after the initial puncture, unless early surgery was chosen or needed. RESULTS
All procedures were successful, with retrieval of diagnostic material ranging from 3 to 350 mL in cases of puncture for therapeutic purpose. Early complications were observed in eight cases (3.9%). In three patients they consisted of transient vasovagal symptoms such as hypotension, sweating, and dizziness, whereas in five patients they consisted of abdominopelvic pain. As summarized in Table 1, early complications were observed more frequently after transabdominal puncture, whereas no correlation was found with the needle gauge. In all patients the symptoms were self-limited and they left the clinic within 20 minutes without medication. Short-term complications were recorded in four patients (1.9%), as summarized in Table 2. One patient complained offever and pelvic pain, with onset 48 hours after puncture. She required hospitalizaFertility and Sterility
--=
DISCUSSION
Table 1 Early and Short-Term Complications Related to the Route of Aspiration* Short-term complications
Early complications Vagal
Pain
Transvaginal (n = 74) Transabdominal (n = 135) 3 (2.2) 5 (3.6) Total procedures 3 (104) 5 (2.3)
Infection
Pain
1 (1.3) 1
(004)
3* (2.2) 3 (1.4)t
* Values in parentheses are percentages. t One subject did not require hospitalization.
tion and underwent surgery with oophorectomy and evacuation of an abscess the next day. Three additional patients complained of pelvic pain 24 to 72 hours after the puncture. Two of them required hospitalization and underwent laparotomy with ovarian cystectomy. At operation, no sign of infection was found but a small amount of thick "chocolate" fluid was seen in the pouch of Douglas. The third patient had similar complains but responded well to analgesic treatment and did not require surgical management. One hundred seventy-two subjects underwent the planned second examination 2 to 3 months after puncture (3 cases had undergone emergency surgery and 36 had undergone surgery after confirmed diagnosis of endometriosis). Persistence of the cyst was observed in all (but four) cases, including all those who had undergone therapeutic aspiration with or without subsequent GnRH-a treatment. In particular, all 12 cases without subsequent treatment with GnRH-a had reaccumulation of the cyst to approximately the initial diameter. Five of the cases with subsequent treatment had reaccumulation exceeding 50% and one patient had reaccumulation to a lesser extent. Nine of 25 patients who had puncture for relief of symptoms experienced regression of pain but 2 subjects with no previous complains reported the onset of pelvic discomfort and 4 with previous pain noted increased discomfort. Thirty-six patients underwent laparoscopic or laparotomic surgery before the planned second scan. All had confirmed endometriomas.
Table 2
Whereas minimal or mild endometriosis either may not require treatment or may be treated with a minimally invasive laparoscopic approach, ovarian endometriomas usually require treatment to relieve pain and promote fertility. Medical treatment alone is usually inadequate, particularly for large masses (18). Few studies have addressed specific interest to fine-needle aspiration of endometriomas. In 1991, Aboulghar et al. (13) reported transvaginal USguided aspiration of pelvic endometriomas in 21 patients. These authors noted reaccumulation of the cyst in only 28.5% of cases and claimed a marked improvement of symptoms in the treated patients. Abu Musa et al. (15) reported three cases of successful treatment of endometriomas by transvaginal sono graphic-guided aspiration. One patient became pregnant after aspiration and the remaining two patients had disappearance of symptoms and complete resolution of the cyst. In our series the therapeutic puncture-aspiration of endometriomas was attempted in very few cases and was not continued because of the extremely disappointing results even when concurrent treatment with GnRH-a was prescribed. Despite the favorable results described by some authors in small studies (13) or case reports (15), little rationale appears to exist for simple aspiration of endometriomas as a therapeutic procedure for endometriomas. Although the epithelial lining of endometriomas is often sparse or absent, some authors have observed that it is the endometrial stroma that is responsible for the bleeding in endometriosis and not the glands of epithelium. This eventually will lead to reaccumulation of old blood, into the cyst. Recently, some authors reported a better outcome for subjects treated with aspiration followed by GnRH-a therapy than for those submitted to aspiration alone (19). In our experience the rate ofreaccumulation ofthe cysts appeared slightly lower among subjects receiving GnRH-a therapy but the results were considered unsatisfactory. One patient conceived after IVF whereas the remaining five eventually required surgical treatment. These results are consistent with the report ofVercellini et al. (8) who
Detail of Cases With Moderate or Severe Complications
Age
Diameter
y
em
36 28 38 32
6 4.5 5 5
Vol. 64, No.4, October 1995
Needle
Route
Complication
Onset
Treatment
h
19 19 19 19
Vaginal Abdominal Abdominal Abdominal
Infection Pain Pain Pain
48 24 72 72
Oophorectomy Cystectomy Cystectomy Analgesics
Zanetta et al. Aspiration of endometriomas
711
observed a limited usefulness of aspiration and lavage of endometriomas under laparoscopic guide and with the observation of Bonilla-Musoles et al. (17) who reported that aspiration of small endometriomas was inefficient for therapeutic purposes. The largest previous experience reported in the literature on aspiration of endometriomas (14) regards 41 women with endometrioma who had failed to conceive during previous IVF programs. These patients underwent transvaginal US-guided fineneedle aspiration of the endometrioma before oocyte retrieval. The authors reported a higher number of oocytes retrieved and a higher pregnancy rate per cycle after the aspiration. They concluded that the improved results probably were due to reduction of extensive ectopic endometrial tissue with improved ovarian response and enhanced follicular accessibility. In our experience, this approach was attempted successfully in only one patient, therefore, any conclusion appears impossible. Aspiration for the relief of symptoms appears questionable. As a matter of fact, some patients experienced a reduction of pelvic discomfort but other patients reported increased pain. The transvaginal route allows the puncture of smaller lesions with increased accuracy and is charged by a lower incidence of early complications than the transabdominal route. This probably is due to the reduced number of tissue layers involved, implying a reduction of pain, and to the better imaging of the target, allowing less spillage of the cystic content. The overall risk of infection after aspiration is low (0.4%), but it must be underscored that the only case of infection in our series was observed after transvaginal aspiration, accounting for a specific risk of 1.3%. Because of the young age of the patients, the diagnostic benefits of aspiration must be evaluated carefully in view of the possible complications. The development of an ovarian abscess or of pelvic inflammatory disease in a young woman wishing future pregnancies is the most undesirable outcome. In previous studies, some authors reported a comparable incidence of infection (20, 21) with transvaginal aspiration of cysts or oocyte retrieval and underscored the need for a careful evaluation of the possible benefits and disadvantages of puncture of cysts. Other authors have reported the occurrence of an abscess after the puncture of an endometrioma during US-guided oocyte retrieval (22). Based on these considerations, we observed a progressive reduction of the cases undergoing fine-needle aspiration in our service. Particularly, the need for differential diagnosis of endometriosis became progressively less frequent with improvement ofmaterials (i.e., high-frequency transvaginal probes) and 712
Zanetta et al. Aspiration of endometriomas
increased experience, whereas therapeutic treatment was abandoned. We conclude that US-guided puncture of endometriomas is feasible either transabdominally or transvaginally for diagnostic purpose. The risks appear low but, in view of the possible consequences on the fertility of young patients in case of complications, this procedure should be limited to select cases. No indication exists for therapeutic aspiration nor for relief of symptoms, whereas the potential of aspiration as a step before induction of ovulation in IVF programs may deserve further investigation. Our data on the feasibility of puncture-aspiration incidentally might provide useful background for future developments, including alcohol injection to fix the internal lining of endometriomas. REFERENCES 1. Cramer DW. Epidemiology of endometriosis. In: Wilson EA, editor. Endometriosis. New York: Alan R. Liss Inc., 1987:522. 2. Olive DL, Schwartz LB. Endometriosis. N Engl J Med 1993; 328:1759-69. 3. Athey PA, Diment DD. The spectrum of so no graphic findings in endometriomas. J Ultrasound Med 1989;8:487-91. 4. Grant EG. Benign conditions of the ovaries. In: Nyberg DA, Hill LM, Bohm-Velez M, Mendelson EB, editors. Transvaginal ultrasound. St. Louis: Mosby Year Book, 1992:187-208. 5. De Crespigny LC, Robinson HP, Davoren RAM, Fortune D. The 'simple' ovarian cyst: aspirate or operate. Br J Obstet GynaecoI1989;96:1035-9. 6. Trio D, Lissoni A, Zanetta G, Pittelli MR, Rangoni G, Dalla Valle C, et al. Agoaspirato ecoguidato di neoplasie ovariche: studio prospettico 1987 -1989. Ultrasonica.1992; 7:45-9. 7. Dordoni D, Zaglio S, Zucca S, Favalli G. The role of sonographically guided aspiration in the clinical management of ovarian cysts. J Ultrasound Med 1993; 12:27 -31. 8. Vercellini P, Vendola N, Bocciolone L, Colombo A, Rognoni MT, Bolis G. Laparoscopic aspiration of ovarian endometriomas. Effect with postoperative gonadotropin releasing hormone agonist treatment. J Reprod Med 1992;37:577-80. 9. Zanetta G, Trio D, Lissoni A, Dalla Valle C, Rangoni G, Pittelli MR, et al. Early and short term complications after USguided puncture of gynecologic lesions: evaluation after 1000 consecutive cases. Radiology 1993; 189:161-4. 10. Christopherson WW. Cytologic detection and diagnosis of cancer; its contributions and limitations. Cancer 1983; 51:1201-8. 11. De Priest PD, Banks ER, Powell DE, Van Nagell JR, Gallion HH, PuIs LE, et al. Endometrioid carcinoma ofthe ovary and endometriosis: the association in postmenopausal women. Gynecol Oncol 1992;47:71-5. 12. Tabbara SO, Covell JL, Abbitt PL. Diagnosis of endometriosis by fine-needle aspiration cytology. Diagn Cytopathol 1991; 7:606-10. 13. Aboulghar MA, Mansour RT, Serour GI, Rizk B. Ultrasonic transvaginal aspiration of endometriotic cysts: an optional line of treatment in selected cases of endometriosis. Hum Reprod 1991;6:1408-10. 14. Dicker D, Goldman JA, Feldberg D, Ashkenazi J, Levy T. Transvaginal ultrasonic needle-guided aspiration of endometriotic cysts before ovulation induction for in vitro fertilization. J In Vitro Fertil Embryo Transf 1991;8:286-9.
Fertility and Sterility
15. Abu Musa A, Takahashi K, Kitao M. Transvaginal sonographic guided aspiration of endometrioma. Int J Gynecol Obstet 1992;40:65-6. 16. Greenbaum E, Mayer JR, Stangler JJ, Hughes P. Aspiration cytology of ovarian cysts in in vitro fertilization patients. Acta Cytol 1992;36:11-8. 17. Bonilla-Musoles F, Ballester MJ, Simon C, Serra V, Raga F. Is avoidance of surgery possible in patients with perimenopausal ovarian tumors using transvaginal ultrasound and duplex color Doppler sonography? J Ultrasound Med 1993; 12:33-9. 18. Schenken RS. Gonadotropin-releasing hormone analogs in the treatment of endometriomas. Am J Obstet Gynecol 1990; 162:579-83.
Vol. 64, No.4, October 1995
19. Donnez J, Nisolle M, Gillerot S, Anaf V, Clerckx-Braun F, Casanas-Roux F. Ovarian endometrial cysts: the role of gonadotropin-releasing hormone agonist and/or drainage. Fertil Steril1994;62:63-6. 20. Rizk B, Lin Tan S, Kingsland C, Steer C, Mason BA, Campbell S. Ovarian cyst aspiration and the outcome of in vitro fertilization. Fertil Steril 1990; 54:661-4. 21. Bennett SJ, Waterstone JJ, Cheng WC, Parsons J. Complications of transvaginal ultrasound-directed follicle aspiration: a review of2670 consecutive procedures. J Assist Reprod Genet 1993;1:72-7. 22. Padilla SL. Ovarian abscess following puncture of an endometrioma during ultrasound-guided oocyte retrieval. Hum Reprod 1993;8:1282-3.
Zan etta et al. Aspiration of endometriomas
713
FERTILITY AND STERILITY Copyright
~")
1995 American Society for Reproductive Medicine
Printed on acid·free paper in U. S. A.
Ultrasound-guided aspiration of endometriomas: possible applications and limitations
Gerardo Zanetta, M.D.* Andrea Lissoni, M.D. Cristina Dalla Valle, M.D.
Diego Trio, M.D. Mariarosa Pittelli, M.D. Giovanni Rangoni, M.D.
Department of Obstetrics and Gynecology, San Gerardo Hospital, Monza, III Branch of the University of Milan, Monza Italy
Objectives: To evaluate the role of needle aspiration in the management of endometriomas. Design: Retrospective evaluation of the activity of the section of interventional ultrasound in a single tertiary care institution. Setting: Department of Obstetrics and Gynecology, Ospedale S. Gerardo, Monza, University of Milan, Italy. Patients: Two hundred nine premenopausal patients underwent aspiration for diagnostic purpose (n = 166), for relief of symptoms (n = 25), or with therapeutic intent (n = 18). Results: Adequate material was obtained by all punctures. Early complications (self-limiting vagal symptoms or pain) occurred in eight cases. Short-term complications consisted of acute abdominal pain in three cases and infection in one. Three women required surgical treatment of the complication. At first examination after aspiration, persistence of the cyst was observed in all but four cases, including all cases who had undergone therapeutic aspiration. Nine patients reported relief of symptoms but six other patients referred onset or worsening of pelvic discomfort after aspiration. Conclusions: Ultrasound-guided aspiration of endometriomas is feasible. The transvaginal route reduces early complication but implies a risk of infection of 1.3%. However, drainage alone is ineffective as a therapeutic procedure and the applications of aspiration of endometriomas appear limited to some cases with diagnostic intent. Fertil Steril 1995;64:709-13 Key Words: Ultrasound, endometriomas, endometriosis, fine-needle aspiration, interventional ultrasound
Endometriosis represents one of the leading causes of hospitalization for gynecological reasons among women in western countries and is one of the most important causes of morbidity and sterility among women of fertile age (1, 2). Although several lesions may be detected only by laparoscopy or laparotomy, a relevant part of endometriotic lesions is represented by palpable cystic masses involving the ovary and/or the fallopian tube. Sonographic features such as thick hypoechoic content, thick capsule, and presence of aggregations allow the diagnosis or the suspicion of endometrioma in the majority of cases (3, 4). The option of puncturing cystic adnexal masses with diagnostic or theraReceived January 10, 1995; revised and accepted April 20, 1995. * Reprint requests: Gerardo Zanetta, M.D., Divisione Ostetricia Ginecologia Ospedale San Gerardo, Via Solferino 16 20052 Monza, Italy (FAX: 39-39-2333820). Vol. 64, No.4, October 1995
peutic purpose has been considered by some authors (5-8) and has proved to be feasible technically (9).
This option remains controversial because of the feared risk of spreading neoplastic cells in case of unsuspected malignancy (10), but this risk is extremely low in young women with endometriomas. Progression of endometriomas to malignancy is negligible at a young age and occurs in a minority of patients in perimenopausal age (11). Few studies specifically address the possible usefulness of fine-needle aspiration of endometriomas (12-15). In the past the aspiration has been proposed for diagnostic purpose (9), to confirm cases with uncertain symptoms and/or sonographic findings before further surgical or medical treatments. It also has been proposed for relief of symptoms (13) in women undergoing medical treatment or as a preliminary step before induction of ovulation in IVF programs (14, 16). Finally, this procedure has been Zan etta et al. Aspiration of endometriomas
709
proposed as one step of a therapeutic approach that includes aspiration with or without medical treatment afterward (8, 13, 15, 17). In this paper we review our recent experience with puncture of endometriomas under ultrasound (US) guidance. MATERIALS AND METHODS
From January 1986 to December 1994, 209 patients with ovarian endometriomas underwent USguided puncture and aspiration at our service of interventional US. Patients ranged in age from 19 to 50 years (mean 34 years; median 34 years). The diagnosis of endometriosis was based upon a combination of clinical signs, macroscopic characters of the aspirated fluid, and cytologic examination. All cysts had macroscopic "chocolate" content at aspiration. The observation of endometrial cells at cytologic examination was considered sufficient for diagnosis and was recorded in 72 cases. In the remaining 137 cases, only macrophages containing hemosiderin were observed in cystic masses that had remained unchanged for 20:3 months before aspiration and were accompanied by clinical signs or symptoms of endometriosis. This second parameter for diagnosis was chosen as it is known that several old endometriomas lack an epithelial lining. The risk of misinterpreting hemorrhagic or luteal cysts appears very low in cases with unchanged morphology for several months and with clinical signs of endometriosis. Patients had been referred for differential diagnosis of endometriotic versus other cystic masses (166 patients), for temporary relief of symptoms during medical treatment of endometriosis (25 patients), and for complete aspiration as a step of a treatment with or without subsequent administration of GnRH agonists (GnRH-a) (18 patients). Ultrasound examination was performed with real time instruments (SS90A, Toshiba, Tokyo, Japan; AU 450 and 540A, Ansaldo, Genua, Italy). A 3.5 MHz transabdominal and a 6.5 MHz transvaginal probe was used. From 1986 to 1989, all patients underwent transabdominal US because of the unavailability of transvaginal probes. Since 1990, transvaginal probes were available and used increasingly. In the last 3 years, transvaginal examination was essential for the definition of the character of the cyst before any further diagnostic approach. Eligibility criteria for puncture were absence of vegetation or papillations, not more than three thin «3 mm thick) septa, and absence of free fluid in the pouch of Douglas. The diameter of the cysts ranged from 10 to 90 mm (mean 55 mm, median 48 mm). All procedures took place on an outpatient basis. One hundred 710
Zanetta et al. Aspiration of endometriomas
thirty-five punctures were performed transabdominally and 74 were performed transvaginally. In both cases no anesthesia nor sedation was used and preparation of the abdomen or vagina was performed with povidone iodide. All instruments used were sterile and disposable, with the exception of reusable plastic guides for the needles and aspiration handles. Chiba needles (Hakko Shoji, Tokyo, Japan) ranging from 17.5 to 19 gauge were used for aspiration of the content. The 17.5-gauge needles were used in 98 procedures, 18 gauge were used in 23, and 19 gauge were used in the remaining 88. Antibiotics were not prescribed routinely in cases of simple diagnostic aspiration but were prescribed after "therapeutic" aspiration or in cases of technically difficult procedures requiring prolonged aspiration time or repeated punctures. A few milliliters of fluid were collected in diagnostic procedures, whereas the cyst was drained completely in the remaining cases. Lavage of the cyst was never attempted. The aspirated fluid always was fixed in 3.8% sodium citrate and was forwarded for cytologic examination. Despite the known limitations of cytologic examination of cystic fluid, it was standard policy to confirm microscopically the macroscopic diagnosis and to exclude the presence of cellular atypia or malignant cells. Early complications were defined as those occurring in the first 24 hours (in the vast majority of cases within a few minutes) after the procedure. Short-term complications were defined as those occurring in the first 5 days after the puncture, according to criteria described in a previous study (9). All patients were scheduled for a second scan 2 to 3 months after the initial puncture, unless early surgery was chosen or needed. RESULTS
All procedures were successful, with retrieval of diagnostic material ranging from 3 to 350 mL in cases of puncture for therapeutic purpose. Early complications were observed in eight cases (3.9%). In three patients they consisted of transient vasovagal symptoms such as hypotension, sweating, and dizziness, whereas in five patients they consisted of abdominopelvic pain. As summarized in Table 1, early complications were observed more frequently after transabdominal puncture, whereas no correlation was found with the needle gauge. In all patients the symptoms were self-limited and they left the clinic within 20 minutes without medication. Short-term complications were recorded in four patients (1.9%), as summarized in Table 2. One patient complained offever and pelvic pain, with onset 48 hours after puncture. She required hospitalizaFertility and Sterility
--=
DISCUSSION
Table 1 Early and Short-Term Complications Related to the Route of Aspiration* Short-term complications
Early complications Vagal
Pain
Transvaginal (n = 74) Transabdominal (n = 135) 3 (2.2) 5 (3.6) Total procedures 3 (104) 5 (2.3)
Infection
Pain
1 (1.3) 1
(004)
3* (2.2) 3 (1.4)t
* Values in parentheses are percentages. t One subject did not require hospitalization.
tion and underwent surgery with oophorectomy and evacuation of an abscess the next day. Three additional patients complained of pelvic pain 24 to 72 hours after the puncture. Two of them required hospitalization and underwent laparotomy with ovarian cystectomy. At operation, no sign of infection was found but a small amount of thick "chocolate" fluid was seen in the pouch of Douglas. The third patient had similar complains but responded well to analgesic treatment and did not require surgical management. One hundred seventy-two subjects underwent the planned second examination 2 to 3 months after puncture (3 cases had undergone emergency surgery and 36 had undergone surgery after confirmed diagnosis of endometriosis). Persistence of the cyst was observed in all (but four) cases, including all those who had undergone therapeutic aspiration with or without subsequent GnRH-a treatment. In particular, all 12 cases without subsequent treatment with GnRH-a had reaccumulation of the cyst to approximately the initial diameter. Five of the cases with subsequent treatment had reaccumulation exceeding 50% and one patient had reaccumulation to a lesser extent. Nine of 25 patients who had puncture for relief of symptoms experienced regression of pain but 2 subjects with no previous complains reported the onset of pelvic discomfort and 4 with previous pain noted increased discomfort. Thirty-six patients underwent laparoscopic or laparotomic surgery before the planned second scan. All had confirmed endometriomas.
Table 2
Whereas minimal or mild endometriosis either may not require treatment or may be treated with a minimally invasive laparoscopic approach, ovarian endometriomas usually require treatment to relieve pain and promote fertility. Medical treatment alone is usually inadequate, particularly for large masses (18). Few studies have addressed specific interest to fine-needle aspiration of endometriomas. In 1991, Aboulghar et al. (13) reported transvaginal USguided aspiration of pelvic endometriomas in 21 patients. These authors noted reaccumulation of the cyst in only 28.5% of cases and claimed a marked improvement of symptoms in the treated patients. Abu Musa et al. (15) reported three cases of successful treatment of endometriomas by transvaginal sono graphic-guided aspiration. One patient became pregnant after aspiration and the remaining two patients had disappearance of symptoms and complete resolution of the cyst. In our series the therapeutic puncture-aspiration of endometriomas was attempted in very few cases and was not continued because of the extremely disappointing results even when concurrent treatment with GnRH-a was prescribed. Despite the favorable results described by some authors in small studies (13) or case reports (15), little rationale appears to exist for simple aspiration of endometriomas as a therapeutic procedure for endometriomas. Although the epithelial lining of endometriomas is often sparse or absent, some authors have observed that it is the endometrial stroma that is responsible for the bleeding in endometriosis and not the glands of epithelium. This eventually will lead to reaccumulation of old blood, into the cyst. Recently, some authors reported a better outcome for subjects treated with aspiration followed by GnRH-a therapy than for those submitted to aspiration alone (19). In our experience the rate ofreaccumulation ofthe cysts appeared slightly lower among subjects receiving GnRH-a therapy but the results were considered unsatisfactory. One patient conceived after IVF whereas the remaining five eventually required surgical treatment. These results are consistent with the report ofVercellini et al. (8) who
Detail of Cases With Moderate or Severe Complications
Age
Diameter
y
em
36 28 38 32
6 4.5 5 5
Vol. 64, No.4, October 1995
Needle
Route
Complication
Onset
Treatment
h
19 19 19 19
Vaginal Abdominal Abdominal Abdominal
Infection Pain Pain Pain
48 24 72 72
Oophorectomy Cystectomy Cystectomy Analgesics
Zanetta et al. Aspiration of endometriomas
711
observed a limited usefulness of aspiration and lavage of endometriomas under laparoscopic guide and with the observation of Bonilla-Musoles et al. (17) who reported that aspiration of small endometriomas was inefficient for therapeutic purposes. The largest previous experience reported in the literature on aspiration of endometriomas (14) regards 41 women with endometrioma who had failed to conceive during previous IVF programs. These patients underwent transvaginal US-guided fineneedle aspiration of the endometrioma before oocyte retrieval. The authors reported a higher number of oocytes retrieved and a higher pregnancy rate per cycle after the aspiration. They concluded that the improved results probably were due to reduction of extensive ectopic endometrial tissue with improved ovarian response and enhanced follicular accessibility. In our experience, this approach was attempted successfully in only one patient, therefore, any conclusion appears impossible. Aspiration for the relief of symptoms appears questionable. As a matter of fact, some patients experienced a reduction of pelvic discomfort but other patients reported increased pain. The transvaginal route allows the puncture of smaller lesions with increased accuracy and is charged by a lower incidence of early complications than the transabdominal route. This probably is due to the reduced number of tissue layers involved, implying a reduction of pain, and to the better imaging of the target, allowing less spillage of the cystic content. The overall risk of infection after aspiration is low (0.4%), but it must be underscored that the only case of infection in our series was observed after transvaginal aspiration, accounting for a specific risk of 1.3%. Because of the young age of the patients, the diagnostic benefits of aspiration must be evaluated carefully in view of the possible complications. The development of an ovarian abscess or of pelvic inflammatory disease in a young woman wishing future pregnancies is the most undesirable outcome. In previous studies, some authors reported a comparable incidence of infection (20, 21) with transvaginal aspiration of cysts or oocyte retrieval and underscored the need for a careful evaluation of the possible benefits and disadvantages of puncture of cysts. Other authors have reported the occurrence of an abscess after the puncture of an endometrioma during US-guided oocyte retrieval (22). Based on these considerations, we observed a progressive reduction of the cases undergoing fine-needle aspiration in our service. Particularly, the need for differential diagnosis of endometriosis became progressively less frequent with improvement ofmaterials (i.e., high-frequency transvaginal probes) and 712
Zanetta et al. Aspiration of endometriomas
increased experience, whereas therapeutic treatment was abandoned. We conclude that US-guided puncture of endometriomas is feasible either transabdominally or transvaginally for diagnostic purpose. The risks appear low but, in view of the possible consequences on the fertility of young patients in case of complications, this procedure should be limited to select cases. No indication exists for therapeutic aspiration nor for relief of symptoms, whereas the potential of aspiration as a step before induction of ovulation in IVF programs may deserve further investigation. Our data on the feasibility of puncture-aspiration incidentally might provide useful background for future developments, including alcohol injection to fix the internal lining of endometriomas. REFERENCES 1. Cramer DW. Epidemiology of endometriosis. In: Wilson EA, editor. Endometriosis. New York: Alan R. Liss Inc., 1987:522. 2. Olive DL, Schwartz LB. Endometriosis. N Engl J Med 1993; 328:1759-69. 3. Athey PA, Diment DD. The spectrum of so no graphic findings in endometriomas. J Ultrasound Med 1989;8:487-91. 4. Grant EG. Benign conditions of the ovaries. In: Nyberg DA, Hill LM, Bohm-Velez M, Mendelson EB, editors. Transvaginal ultrasound. St. Louis: Mosby Year Book, 1992:187-208. 5. De Crespigny LC, Robinson HP, Davoren RAM, Fortune D. The 'simple' ovarian cyst: aspirate or operate. Br J Obstet GynaecoI1989;96:1035-9. 6. Trio D, Lissoni A, Zanetta G, Pittelli MR, Rangoni G, Dalla Valle C, et al. Agoaspirato ecoguidato di neoplasie ovariche: studio prospettico 1987 -1989. Ultrasonica.1992; 7:45-9. 7. Dordoni D, Zaglio S, Zucca S, Favalli G. The role of sonographically guided aspiration in the clinical management of ovarian cysts. J Ultrasound Med 1993; 12:27 -31. 8. Vercellini P, Vendola N, Bocciolone L, Colombo A, Rognoni MT, Bolis G. Laparoscopic aspiration of ovarian endometriomas. Effect with postoperative gonadotropin releasing hormone agonist treatment. J Reprod Med 1992;37:577-80. 9. Zanetta G, Trio D, Lissoni A, Dalla Valle C, Rangoni G, Pittelli MR, et al. Early and short term complications after USguided puncture of gynecologic lesions: evaluation after 1000 consecutive cases. Radiology 1993; 189:161-4. 10. Christopherson WW. Cytologic detection and diagnosis of cancer; its contributions and limitations. Cancer 1983; 51:1201-8. 11. De Priest PD, Banks ER, Powell DE, Van Nagell JR, Gallion HH, PuIs LE, et al. Endometrioid carcinoma ofthe ovary and endometriosis: the association in postmenopausal women. Gynecol Oncol 1992;47:71-5. 12. Tabbara SO, Covell JL, Abbitt PL. Diagnosis of endometriosis by fine-needle aspiration cytology. Diagn Cytopathol 1991; 7:606-10. 13. Aboulghar MA, Mansour RT, Serour GI, Rizk B. Ultrasonic transvaginal aspiration of endometriotic cysts: an optional line of treatment in selected cases of endometriosis. Hum Reprod 1991;6:1408-10. 14. Dicker D, Goldman JA, Feldberg D, Ashkenazi J, Levy T. Transvaginal ultrasonic needle-guided aspiration of endometriotic cysts before ovulation induction for in vitro fertilization. J In Vitro Fertil Embryo Transf 1991;8:286-9.
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15. Abu Musa A, Takahashi K, Kitao M. Transvaginal sonographic guided aspiration of endometrioma. Int J Gynecol Obstet 1992;40:65-6. 16. Greenbaum E, Mayer JR, Stangler JJ, Hughes P. Aspiration cytology of ovarian cysts in in vitro fertilization patients. Acta Cytol 1992;36:11-8. 17. Bonilla-Musoles F, Ballester MJ, Simon C, Serra V, Raga F. Is avoidance of surgery possible in patients with perimenopausal ovarian tumors using transvaginal ultrasound and duplex color Doppler sonography? J Ultrasound Med 1993; 12:33-9. 18. Schenken RS. Gonadotropin-releasing hormone analogs in the treatment of endometriomas. Am J Obstet Gynecol 1990; 162:579-83.
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19. Donnez J, Nisolle M, Gillerot S, Anaf V, Clerckx-Braun F, Casanas-Roux F. Ovarian endometrial cysts: the role of gonadotropin-releasing hormone agonist and/or drainage. Fertil Steril1994;62:63-6. 20. Rizk B, Lin Tan S, Kingsland C, Steer C, Mason BA, Campbell S. Ovarian cyst aspiration and the outcome of in vitro fertilization. Fertil Steril 1990; 54:661-4. 21. Bennett SJ, Waterstone JJ, Cheng WC, Parsons J. Complications of transvaginal ultrasound-directed follicle aspiration: a review of2670 consecutive procedures. J Assist Reprod Genet 1993;1:72-7. 22. Padilla SL. Ovarian abscess following puncture of an endometrioma during ultrasound-guided oocyte retrieval. Hum Reprod 1993;8:1282-3.
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