Pelvic endometriosis: CELSO-RAMdN SAMI

GARCiA,

S.

DAVID,

Yhilcd~~lphitr,

Infertility

and pelvic pain

M.D.

M.D.

PmtI.\yIzwC

A multifactorial approach was used by the authors to analyze data from 119 women with endometriosis and infertility. Conservative surgical procedures afforded a mean pregnancy rate of 37.7 per cent for those women with significant disease. Only 6.7 per cent became pregnant when the proposed surgery was declined. There was an inverse relationship in severity of endometriotic involvement and pregnancy rate. The mean pregnancy rate among 17 patients with minimal disease for whom surgery was discouraged was 64.7 per cent; all pregnancies occurred within the first 2 years of follow-up. Relief of pelvic pain was dramatic, especially following presacral neurectomy. Laparoscopic selection of cases further reinforces the importance of grading severity of endometriosis prior to embarking on restorative surgery. Presacral neurectomy, despite reinforcement of pain relief, did not appear to contribute significantly to the occurrence of pregnancy. (AM. J. OBSTET. GYNECOL.

THERE

129:

1977.)

to be a concensus

APPEARS

lationship

740,

between

regarding

endometriosis

and

though medical approaches to the dometriosis have been suggested, their effectiveness fertility.‘-” Operative some us

(C.-R.

G.),

contrast.

earlier

of

surgery

yielded

for

the

temporary in subsequent

symptomatic fertility.

of

cent

the

was so severe

cation ence senior versity

suggested.

The

is to review with

purpose our

endometriosis

author, admitted of Pennsylvania.

of the

more in to

recent

who

rate,

coital

finally

for dys-

et al.;’ This U.)

similar

iI1 the

present

communi-

primigravid,

personal

Hospital

patients of

per

experiof the

cent)

the

\vere gravidity. ‘I‘he

patients

was

four

None emotional evaluated

and

by one

description I 19 patients,

IO prr

Endoof thtb

to a classifica-

the

(4.3

of was

scverit!

on the Of

age

cent).

The

hv Acosta.

nulligt-avid,

and

per

~\as applied

note.

were in Fig.

a mean

acc~ording

proposed based

operative

greater offspring.

Uni-

to that

classification

patients

in all 56 women

laparotonly.

independently

distortion procedure

I 19 (77.3

leas catalogued

of

1. 1966

Endomctriosia

histologically

underwent

endometriosis

fre-

in

Hospital

outlined

with

category.

~r;as confirmed

on

tion

zyc,nlen

this

b?- endoscop)

metriosis

adnexal surgical

infertile the

confirmed In

into

pattern

pa-

physical

Januarv

In general,

to the Hou fifty-four

fell

from

3 1, 1976.

hundred years

of these and

at the

Pennsylvania

according

I. One

records

infertility

of endomctriosis of

December

28.9

the

with

suggestive

managed

reviewed

presented

University

through

Based

affect

the

of

was adopted except when

as to adversely

quency. In those instances where was estensise, a pelvic restorative was

pregnancy

disease.”

\vho

findings

with

endometri-

experience. a policy of expectancy patient with minimal disease

pareunia

women

of us (S. S. D.)

tients

in-

of one

to moderate

a 58 per

extent

One

Alof envary OII

experiences among

minimal

little more than little improvement

uncorrected

infertility.

management opinions

pseudopregnancy

diagnoses

osis offered relief with

this the

In the

Material and methods

re-

when there is associated treatment has also engendered

controversy.

clinical

the

associates. of us (S. S. contained IO5

(8.4

per

cent)

cent)

pi-esentcd

(88.2 \vcre with

had produced Inore status of randomly

than one selected

using

Symptom

Checklist. an instrument the clinical assessment

the

Hopkin’s

which has provetl of the patient’s

useful emotional

in

status."

Therapy support

consisting was supplied

cndometriosis. mean Surgrry degrees

740

‘I’heir

of for mean

duration of infertility was recommended of severity

expectancy 15 patients age

and who

was 29.1

emotional had

minimal

years,

with

a

of 3.3 years (l‘able I). in 71 lvornen \vith various

of cndometriosis.

Their

mean

age

Pelvic

D~ognos~s

ConfIrmed

endometriosis

741

By

119 Women (77.2%) Lo~orosco~v or Culdoscoov

Surgery

Recommended-86 Vorled

Surgery

Women

(72.3%)

Surgery

4

Sevwty

Refused

MinImal

Surgery

Accepted

71 Women

(El2 6%)

Fig.

was

28.9

years,

\vith

3.4

years

(Table

II).

Sixteen male

a mean

conservative

the

16 patients

not

undergo

attempt

had

or

that

pelvic

either

Severe

1. Suspected

(51 5%)

endometriosis

infertility

severely

was

of

presented

severe

operacion.

Five

conservative

male

surgery

of

and

did

insisted

despite

on

the

Adhesions blunt

trolled. frequent

carefully

dissected

Hemostasis

in

Endometriomas

rather

were

en bloc bowel

when

muscles.

ligament

were

surgically

except

with

the

with

sharp

dissection

areas

along

the

sected;

reattachment

using

deeper

layers

Struli

cervix

a circular,

purse string-like, spiraling suture starting producing hemostasis as well as obliterating space.

The

capsule

edges

continuous

baseball stitch, a smooth leaving

and

peritonealizcd tures. \+Then

were

modified ter

assure

approximated

inverting surface.

using No. 4-O or No. polyglycolic acid sutures

they were adopted exclusively. ,A presacral neurectomy \vas dependent pareunia.

In-

were

re-

in order

an anterior

suspension

0

were

and

and

pelvic

MN171 29.1 YJ.3 17 II ti4.7

(mo.)

(range)

adnexa

(12.7

per

cent)

additional

6 (2-21)

by end of‘ 12 months: of 24 months.

during

of

of the

the

postoperative

7 1 women

procedures

adhesions

with

such pelvic

were was carried received

promethazine

reconstruction,

carried

out

undergoing

as myomectorny, out.

or Incidental

routinely.

the regimen

of dexamethasone

recommended

by Replogle

and

as-

was

5.5

to avoid

Results General

continuous, at the the

days,

with

a

selectively

to betpositioning

factors.

with

morbidity

base, dead

The

mean

of

3 to

a range was

observed.

No

ment was encountered. Pregnancy occurrence. patients

who

were

endometriosis, surgery. fused. per

superior

treatment

sociates.’

3-O absorbable subecame available,

was performed

endometriosis

(yr.)

and

All patients

upon the severity of dysmenorrhea or dysAt the end of the pelvic reconstruction, a Olshausen

uterus

appendectomy

the edges slightly All areas were

performed,

of minimal surgical

salpingo-oophorectomy

incised and the endomeby blunt dissection. The

with

cases

phase.

lysis

per-

scissors.

ureters

the

surgery,

broad

by use of No.

The

progressed

them. Ovaries were were resected mainly closed

the

(I5 2%)

by laparoscopy-no

In nine

the

were

ligaments

suture.

of

resected

of

Women

women.

I. Seventeen

healing

through

on Surgery

Notr: lO/ 11 = 99.9 per cent pregnant 1 li I1 = 100 per cent pregnant by end

con-

were

resection

was to the

as the dissection

were

alld

ligaments

damaging triomas

sharp

electrocoagulated

extension

uterosacral

interrupted

identified

was and

formed

absorbable

not

uterosacral

volved

both

5

Mean age (yr.) Duration of infertility Total cases h’o. of pregnancies Percent Interval to pregnancy

an

was used with suction to locate

excised,

there

Dissection

and

154

Table

grave

was meticulously

In the main, bipolar coagulation saline irrigation and fine-tip

bleeders. but

were dissection.

involvement

D&Cl

Eleven

factors

patients

severe

7

severity

advised.

(277%)

Very lnslstent

3%)

compromised of such

not

Facfors

It Women‘((33

prognosis. and

Mate

x

17 Woment

of

endometriosis

surgery

at

Supportive

diagnosed

patients

fertility

duration

33 Women very

,Nryl (174%)

Recommended-

FIndIngs

Temponzmg

-rr 15 Women

Not

86 Seventy-one

Twenly-three cent)

because

contributed (64.7 per

to cent)

need

As seen

diagnosed were

the

for

significant

blood

2, of the

conservative: treated

while

of

were

not

pelvic

while

15 re-

patients

(32.-l

the

one (6.7 per cent) became was not recommended findings

119

as having

surgery

ovum transport became pregnant.

replace-

endoscopy

offered

accepted pregnant,

stay No

in Fig.

by

surgically

became

fused surgery, only (P < 0.05). Surgery tients

hospital 8 days.

adjudged

15 who

re-

pregnant in 17 pato have

disturbances. Eleven This represents a

71. ,J. ORsrET. GYNFCOI 109: 850,

1971. 13. Williams, ‘I‘. J.: The role of.surgcry in the management endometriosis. Mayo Clin. Proc. 50: 198. 197.5.

of

maneuver by either laparoscopy or laparotomy has been tried by the authors. It is intriguing to note that 22 of the 23 \vomen in the operative series conceived lvithin 24 months. This might be consistent \iith Sampson’s regurgitation thesis. Reimplantation of’ menstrual fragments through patent tubes might be expected, in the passage of sufficient time, to produce recurrence of the original pelvic disease and the same factors--whether mechanical or distortional-that actively prevented fertility in the first place. I woulcl like to ask the authors it’ thee have had an opportunity to p?I-form laparoscopy agail) in some of those patients in \vhom treatment failed. Finally. I am intrrested in the allusion to the possible use of danazol, the “antigonadotl.opiI1,” in the six of 17 patients with minimal invol\,ement who havt. IIOI so f’al responded to “supportive” therapy. Ill an its \‘Ct Ullpllblished but convincing piece of research on rats, it was found that this compound acts only on the hypothalamus to inhibit the luteinizing hormone release factor, without any effect whatsoe\-er on any of the pituitar! hormones. Ovulation and progesterone production are as surely prevented as they arc tvith pseudopregnanc\ regimens. and the resulting amenorrhea is devoid of‘ the side effects from massive steroidal control. I)ana~ol may then take its place among nonsurgical choices. cspecially for those in whom continuing intertilit\, can Ix tolerated. This is a most carefully prepared and helpful contribution to the literature on endometriosis. DR. JAMES A. MERRILL, Oklahoma City, Oklahoma. Endometriosis is a unique pothhgir r~r/~, occurring commonly and demonstrating certain characteristics of malignancy as well as inflammation. It wry be a c/i.w\~ ot‘ protean nature, accounting for man\. davs of disability, but the exact incidence is difficult to determine because the lesions exist in many patients without (ausing svmptoms and the diagnosis is made with accuracy only at operation. The symptoms of endomctriosis are extremely variable. There ma); bc extenrivc‘ entlome-

Pelvic endometriosis: infertility and pelvic pain.

Pelvic endometriosis: CELSO-RAMdN SAMI GARCiA, S. DAVID, Yhilcd~~lphitr, Infertility and pelvic pain M.D. M.D. PmtI.\yIzwC A multifactorial...
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