Microsurgery of endometriosis in infertile patients

Transcription

1 FERTILITY AND STERILITY Copyright e 1984 The American Fertility Society Printed in U.SA. Microsurgery of endometriosis in infertile patients Stephan Cordts, M.D. Willy Boeckx, M.D. Ivo Brosens, M.D., Ph.D.* Centre of Microsurgery, Academic Hospital St. Raphael-Gasthuisberg, Leuven, Belgium From January 1973 to December 1980,176 infertile women with endometri~sis were treated with atraumatic and microsurgical techniques. None of these patlents received preoperative or postoperative antigonadotr0/j.in therapy. T~e deg~ee of endometriosis in these patients was classified accordmg to the scalmg pomt system of The American Fertility Society. After 2 years the cumulative pregnancy rate of the severe group (40%) was not different from that of the mild (43%) or moderate group (45%). It is therefore suggested that the use of microsurgical techniques can improve the pregnancy outcome in patients with severe endometriosis. Fertil Steril 42:520, 1984 It is generally accepted that the severe and extensive degrees of endometriosis are associated with infertility because of mechanical factors which can interfere with ovulation, ovum release, and ovum pickup. On the other hand, recent reportsl, 2 have questioned whether endometriosis in its mild or even moderate degrees is a cause of infertility. Other authors 3, 4 have suggested that endometriosis in its initial stage is a consequence, rather than a cause, of infertility. It is therefore questionable whether surgery or antigonadotropin treatment of mild endometriosis will improve infertility. On the other hand, function-retaining surgery of severe and extensive degrees of endometriosis may be beneficial by reducing the mechanical factors of infertility. In the present study the results of function-retaining microsurgery are evaluated in patients with severe and extensive degrees of endometriosis and compared with the results of patients with a mild or moderate degree of endometriosis. Received November 21,1983; revised and accepted June 6, *Reprint requests: Ivo Brosens, M.D., Ph.D., Centre of Microsurgery, Academic Hospital, St. Raphael-Gasthuisberg, Herestraat, 49, 3000 Leuven, Belgium. 520 Gordts et a1. Endometriosis microsurgery MATERIALS AND MEmODS PATIENT SELECTION AND CLASSIFICATION The present study, extending from January 1973 to December 1980, includes the retrospective analysis of 176 cases of infertility with endometriosis, which were selected for conservative surgery. The severity of endometriosis was classified according to the criteria of The American Fertility Society.5 All patients received preoperatively a full infertility investigation including basal body temperature chart, sperm analysis, sperm antibodies, postcoital test, plasma progesterone, and/or endometrial biopsy and laparos-. copy. The criteria used for normal semen analysis were> 20 x 106/ml, > 60% with good motility, and < 40% abnormal forms. When indicated, treatment was given for associated factors of infertility such as anovulation or short luteal phase by clomiphene and human chorionic gonadotropin before and after surgery. MICROSURGICAL TECHNIQUES The microsurgical techniques employed have been described in detail by Boeckx et al. 6 The Fertility and Sterility

2 Figure 1 At the posterior side of the ovary an elliptical incision is made following the axis between the fimbria ovarica and the ovarian ligament. basic principle of function-retaining microsurgery for endometriosis in infertility is to eliminate selectively the endometriotic implants and adhesions and to restore the surface and the function of the pelvic organs. PERITONEAL ENDOMETRIOSIS This superficial type of endometriosis can be treated easily with bipolar coagulation. Small lesions < 5 mm in diameter are grasped with the bipolar forceps and under continuous irrigation are coagulated. Foci of invasive peritoneal endometriosis are resected with the electromicrosurgery needle. The small peritoneal gaps are then closed by 8-0 nylon inverted stitches. usually located on the posterior ovarian surface, an elliptical incision of the ovarian surface is made over the endometrioma, usually following a line between the fimbria ovarica and the ovarian ligament (Fig. 1). This incision is made with the electromicrosurgery needle. Subsequently, two glass hooks are used to lift and stabilize the healthy ovarian tissue; and a small-tooth forceps is used to grasp the endometrioma (Fig. 2). With blunt, curved microscissors a plane of cleavage is forged between the endometrioma and the normal ovarian tissue. Continuous irrigation with Hartmann's solution will help in finding the plane of cleavage, together with a steady pull on the endometrioma. With the scissors slightly opened, the dissection is partly sharp, partly blunt. Care must be taken to remove all abnormal tissue. Mter total removal, bipolar coagulation ensures good hemostasis. Continuous irrigation helps to locate the small bleeding points. Reconstruction ofthe ovary starts at the fimbrial side of the ovary, and suturing is done to keep the line of scar formation along the axis and on the posterior aspect of the ovary (Fig. 3). Six to seven separate inverted 5-0 Prolene stitches are placed so that the knot is lying deep in the ovarian tissue. Big bites of tissue are taken to obtain good hemostasis and to avoid dead space. Final closure of the ovarian surface is performed (with 8-0 nylon) under high magnification. Special care must be taken to invert the cut edges of the incision in the ovary so OVARIAN ENDOMETRIOMA After division of adhesions, the pelvic organs are lifted, the pouch of Douglas is packed with wet abdominal packs, and the ovary and tube of one side are placed on a Silastic sheet as for tubal microsurgery. Superficial implants are coagulated between the slightly opened jaws of bipolar forceps while avoiding burning the surrounding normal ovarian surface. Use of the operating microscope helps in judging the extent of coagulation. Filmy adhesions are lifted with jeweler's forceps, and the tip of the electro microsurgery.needle will resect these implants without cutting into the ovary. Endometriomas of the ovaries can be removed carefully while retaining most of the normal ovarian tissue. Because the endometriomas are Figure 2 Careful dissection of the endometrioma. Gordts et ai. Endometriosis microsurgery 521

3 the raw surface and tacked into place with 6-0 Prolene or with tissue-adhesive material (butyl2-cyanoacrylate, Histoacryl, B. Braun AG, Melsungen, West Germany). ADJUVANT THERAPY Figure 3 Closure of the ovary in two layers:' first layer, inverted 5-0 Prolene stitches; second layer, closure of the ovarian surface with continuous 8-0 nylon. that only smooth ovarian surfaces are apposed. A continuous 8-0 nylon suture is used unless abnormal tension is present. In these instances, interrupted 8-0 stitches are placed in an inverted manner'so that the knots end inside the ovary (Fig. 4). The final reconstruction results in an undamaged anterior surface of the ovary. If adhesion formation occurs, it will largely be restricted to the posterior surface of the ovary and the fossa ovarica. OVARIAN ADHESIONS In severe degrees of endometriosis virtually no plane of cleavage can be found between the ovarian surface and the posterior leaf of the broad ligament. Sometimes little gaps can be found in the adhesions, into which glass hooks can be slid; and magnification helps to identify the different layers of adhesions. With the electromicrosurgery needle the adhesions are sectioned, the needle being protected by a glass hook. Endometriotic cysts, which have no proper capsule, often rupture during the dissection. The ovary is lifted progressively' and exposed. The endometriotic tissue is removed as described above. The raw peritoneal surface of the posterior leaf of the broad ligament and the hilus of thf ovary needs further surgery: after hemostasis tht:. surface can be repaired by approximation and closure of the surrounding healthy peritoneum when the. defect is small. When larger peritoneal raw surfaces remain, a fat-free peritoneal graft is taken from over the bladder or along the anterior margin of the incision. The graft is spread over 522 Gordts et ai. Endometriosis microsurgery Additional surgical procedures, such as presacral neurectomy, resection of the sacrouterine ligaments, and appendectomy, were not performed. In severe endometriosis, anteversion of the uterus was performed by shortening the round ligaments. Broad spectrum antibiotic cover (ampicillin and cloxacillin) was given routinely and was started 2 hours before the operation andcontinued for 5 days. Corticosteroids were not used except in a few patients with extensive peritoneal damage. The standard regimen was 1 gm hydrocortisone acetate in the pelvic cavity before abdominal closure and dexamethasone in equally divided doses for 6 days, starting with 6 mg and then 5, 4, 3, 2, and 1 mg. No antigonadotropin treatment was used preoperatively, postoperatively; or during, the follow-up period of the present study. STATISTICAL METHODS Cumulative pregnancy rates were calculated according to the life-table method described by Kaplan and Meier. 7 For entering the study the date of intervention is considered as the starting point for each patient. The end points are the approximate date of conception, loss of follow-up, and closure of the study. If, after the intervention, Figure 4. Closure of the ovarian surface with separated inverted stitches. Fertility and Sterility

4 Table.l. Characteristics of the Patients Age (yr) Stage of endometriosis I IT III IV E; & > Previous gestation Abortion Ectopic 3 Live birth 1 2 Duration of infertility (mo) < > Male factor 9 (45%) 32 (32%) 18 (33%) 1 Subfertile Donor insemination Total no. of patients there has been no follow-up at all, the patient stays in the study for a period of 6 months. Because the follow-up ended in December 1981; all the patients.had the possibility of a follow-up for at least 1 year. One-month intervals are used for the analysis. The average monthly fecundity or fecundity rate is calculated for each group and for the overall group according to Cramer et al. 8 and Rock et al. 9 RESULTS The characteristics of the patients are shown in Table 1. There was no statistically significant difference between the groups with respect to age, parity, and associated factors of infertility. The patients with severe endometriosis had, in general, a longer duration of infertility than the patients with mild or moderate endometriosis. Gross pregnancy rates and pregnancy outcome by severity of endometriosis are tabulated in Table 2. The cumulative pregnancy rate according to the life-table method for the total group is shown in Figure 5. After 1 year a cumulative pregnancy rate of 28.8% was observed, which increased to 40.5% after 24 months and to 60% after 48 months. The mean follow-up was 33 months, ranging from 1 to 57 months. There was no statistically significant difference in the cumulative pregnancy rate between mild, moderate, or severe groups of endometriosis (Fig. 6). Comparison of the cumulative pregnancy rate between groups I and II combined and groups III and IV combined showed no significant difference after ± 36 months (Fig. 7). The average monthly fecundity, or the fecundity rate, was 2.33%, 2.31%, and 2.14% for groups I, II, and Ill, respectively. The majority of conceptions (63%) occurred during the first year after surgery. Eighty-three percent of the conceptions had occurred by the end of the second postoperative year (Table 3). In the group of patients whose husbands had subfertile semen, the cumulative pregnancy rate after 1 year was 14%, as compared with 32% in the normal group (Fig. 8); and the fecundity rate fell from 2.5% to 1.5% (P = 0.06). Donor insemination was performed in 12 patients, and pregnancy occurred in 5 of them. Second-look laparoscopy was performed. 18 months or more after surgery in 39 patients. Recurrence of peritoneal implants of endometriosis was found in 11 patients (Table 4). Adhesions with partial ovarian enclosure or tubal distortion were present in 13 patients. In 17 patients the laparoscopic findings were normal. Six of these patients became pregnant after second-look laparoscopy~ No obvious explanation for the persisting infertility was present in the other 11 patients. DISCUSSION The use of microsurgical techniques for conservative surgery of endometriosis may seem overzealous and, indeed, superfluous. In severe endometriosis the lesions are extensive, and the pelvic organs are fixed deep in the pelvis. Mobilization of the organs, particularly of the ovaries, results in extensive damage to the pelvic peritoneum and surface of the pelvic organs. It may be questioned, therefore, whether microsurgical techniques could benefit patients with extensive lesions. During recent years, the use of careful surgical Table 2. Unadjusted Pregnancy Rate and Outcome of Pregnancy by Severity of Endometriosis (American Fertility Society Classification) No. of patients Patients pregnant Living child 8 33 Spontaneous abortion 9 Ectopic pregnancy Stage of endometriosis I IT III IV (40%) 42 (42%) 19 (36%) 1 (25%) 16 3 Gordts et ai. Endometriosis microsurgery 523 1

5 MICROSURGICAL TREATMENT OF ENDOMETRIOSIS c "mul,t,,, pregoa",y cat, ( cases) OlIO '" m (umulatlve pregnancy rate ". o :;'. MICROSURGICAL TREATMENT OF ENDOMETRIOSIS ( : 176 cases) 11 II... III III II II II:: II: til III ~H III 1111'1.... Itl "" " III III A F S classification I m Figure 5 Cumulative pregnancy rate of the total group. Figure 7 Comparison of the cumulative pregnancy rate of groups I and II versus groups III and IV according to The American Fertility Society classification system. techniques has been advocated 9, 10 for conservative surgery of endometriosis, and the outcome after such treatment has apparently improved. In the present study, loops and careful surgical techniques were used during the stage of dissection and mobilization of the pelvic organs. After adequate exposure, the operating microscope was swung over the operating field, and ovarian and tubal surgery was performed under the microscope. The magnification of the operating microscope is of great assistance in carefully dissecting endometriotic from normal ovarian tissue, in removing the superficial implants, in severing the numerous adhesions from the ovarian and tubal surface, and in carefully reconstructing the ovary, particularly the ovarian capsule. The surgical procedure was intended to remove all the endometriosis and its sequelae from the ovary, the fallopian tubes, and the pelvic peritoneum and to carefully reconstruct the pelvic organs and the peritoneum. More extensive surgical procedures to remove deeper implants by resection of the sacrouterine ligaments or the rectovaginal septum or procedures which were not strictly indicated, such as appendectomy or presacral neurectomy, were not performed in order to MICROSURGICAL TREATMENT OF ENDOMETRIOSIS ( : 176 cases) Cumulative pregnancy rate [umu(cltlve pregnancy rate MICROSURGICAL TREATMENT OF ENDOMETRIOSIS ( : 176 cases) !I III Ii," '".1I'llilllllll 1IIIIItllolll"IIIIIII""IIIII""'111 '''''111,...,... : :... A F S classlftcatlon... II , II III m OlIO 0621 ". "'" " 1:11: :111:,:1111:1111 II.... " II..... II '".. '11" o II" " , Spermlogram abnormal I normal m Figure 6 Comparison of the cumulative pregnancy rate of the different groups, divided according to The American Fertility Society classification system. 524 Gordts et al. Endometriosis microsurgery Figure 8 After 1 year the cumulative pregnancy rate of patients whose husbands had subfertile semen (48 cases) was 14% versus 32% for the group of patients with a normal fertile husband or donor insemination (128 cases). Fertility and Sterility

6 Table 3. Occurrence of Pregnancies According to the Months After Intervention Months No. % avoid increased risk of infection or damage to the peritoneum. The operating time even with the microsurgical technique was not excessive and rarely exceeded 3 hours. The atraumatic reconstruction of the surface of the tuboovarian tissues and the surrounding peritoneum is of primary importance in preventing postoperative adhesions. In our hands, the use of free peritoneal grafts fixed with tissue-adhesive material lowers the risk for adhesion formation, as proven by second-look laparoscopy performed in some ofthe patients. Careful preparation ofthe peritoneal graft using high-power magnification for the dissection and freeing it completely of fat is most important. Administration of corticosteroids was restricted to those patients (15%) in whom, at the end of the intervention, it seemed impossible to restore totally the raw peritoneal surface and in whom, in the dissection of adhesions, the serosal layer of the bowel had not been damaged. In contrast to the sequelae of pelvic inflammatory disease, the fallopian tube in endometriosis has a normal mucosal lining,l1 so that reconstruction of the tuboovarian tissues may be more beneficial in endometriosis. This is shown by the rare occurrence of ectopic pregnancy even following extensive surgery for endometriosis. The present data suggest that in severe endometriosis the pelvic organs can be reconstructed and that a pregnancy rate can be obtained similar to that among patients with mild or moderate endometriosis. In view of the fact that the majority ofpregnancies occur during the first postoperative year, antigonadotropic treatment has not been used in our Table 4. Recurrence of Endometriosis Diagnosed at Second Look Laparoscopy Performed 18 Months After Surgery in Patients Who Failed to Conceive I or II III or IV Total No Recurrence 6 (26%) 5 (31%) 11 (28%) patients, even when deeper implants of endometriosis were not removed_ Ovarian stimulation with clomiphene or gonadotropins has been restricted to cases of anovulation or those manifesting short luteal phase. The risk of ovarian cyst or pseudoperitoneal cyst formation is probably greater when periovarian adhesions are present. The assessment offertility of the husband is an important factor in evaluating the prognosis_ It is important to note the high incidence of male infertility in the present study. The frequent association of endometriosis with other factors such as male infertility supports the hypothesis that in the initial stages those factors may be of more importance in causing subfertility in these couples. However, further investigation of the pathophysiology-of endometriosis is needed before a rational conservative approach to this disease in infertility can be established. REFERENCES 1. Schenken RS, Malinak LR: Conservative surgery versus expectant management for the infertile patient with mild endometriosis. Fertil Steril 37:183, Seibel MM, Berger MJ, Weinstein FG, Taymor ML: The effectiveness of danazol on subsequent fertility in minimal endometriosis. Fertil Steril 38:534, Brosens I, Koninckx P, Corvelyn P: A study of plasmaprogesterone, oestradiol 1713, prolactin and LH levels and of the luteal phase appearance of the ovaries in patients with endometriosis and infertility. Br J Obstet Gynaecol 85:246, Koninckx P, Ide P, Vandenbroucke W, Brosens I: New aspects of the pathophysiology of endometriosis and associated infertility. J Reprod Med 24:257, American Fertility Society: Classification of endometriosis. Fertil Steril 32:633, Boeckx W, Gordts S, Brosens I: Ovarian microsurgery. In Microsurgery in Female Infertility, Edited by PG Crosignani, BL Rubin. London, Academic Press, 1980, p Kaplan EL, Meier P: Nonparametric estimation from incomplete observations. J Am Stat Assoc 53:457, Cramer DW, Walker AM, Schiff I: Statistical methods in evaluating the outcome of infertility therapy. Fertil Steril 32:80, Rock JA, Guzick DS, Sengos C, Schweditsch M, Sapp KC, Jones HW Jr: The conservative surgical treatment of endometriosis: evaluation of pregnancy success with respect to the extent of disease as categorized using contemporary classification systems. Fertil Steril 35:131, Buttram VC Jr: Conservative surgery for endometriosis in the infertile female: a study of206 patients with implications for both medical and surgical therapy. Fertil Steril 31:117, Vasquez G, Boeckx W, Winston RML, Brosens I: Human tubal mucosa and reconstructive microsurgery. In Microsurgery in Female Infertility, Edited by PG Crosignani, BL Rubin. London, Academic Press, 1980, p 41 Gordts et ai. Endometriosis microsurgery 525