SURGICAL TREATMENT OF ENDOMETRIOSIS IN THE INFERTILE FEMALE: A MODIFIED APPROACH

SCIENTlFICARTICLES FERTILITY AND S!'ERILITY Copyright 1979 The American Fertility Society Vol. 32, No.6, December 1979 Printed in USA. SURGICAL TREATMENT OF ENDOMETRIOSIS IN THE INFERTILE FEMALE: A MODIFIED APPROACH VEASY C. BU'ITRAM, JR., M.D. Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas 77030 Two groups of infertile women underwent conservative surgery for endometriosis, group I (107 patients) prior to 1970 and group II (138 patients) after 1970. To determine whether modifications to the surgical approach after 1970 further increased the likelihood of conception, postoperative pregnancy rates were examined. The data suggest that postoperative pregnancy rates can be improved by (1) removal rather than "repair" of diseased adnexa if the involvement is. unilateral and (2) leaving diseased areas undisturbed where excision or cauterization may predispose to the development of postoperative ovarian and/or tubal adhesions. The current surgical technique (used for group II) is described in detail. Fertil Steril 32:635,1979 In two earlier studies we reported results of conservative 1st year. (The 26 women were considered else surgery in a total of 313 infertile women where, however, as surgical failures. 2 ) More de with endometriosis. I, 2 The pregnancy rates observed in both studies support the belief, shared by others,3-9 that conservative surgery in such cases is beneficial. However, a review of published reports reveals little uniformity in the surgical technique utilized; even our own procedure was not the same for the two groups reported. The purpose ofthis paper is to describe our most recent technique and to compare results with those of our earlier approach. Postoperative pregnancy rates were examined in an effort to determine whether the modifications employed after 1970 have further increased the likelihood of conceptiontailed discussion of the 42 women excluded here because of male infertility factors appeared in a previously published article. 2 Although the exclusions biased the pregnancy rates in both groups, they were necessary for comparisons of data. All patients thus fulfilled the following criteria: they were married, had been attempting to conceive for 1 year or more, and had histologically diagnosed endometriosis. Their husbands had normal conventional spermograms. Although endometriosis was suspected as the primary cause of infertility in all cases, some patients in both groups were treated for additional problems which might have affected their ability to conceive. In group I, 12% of patients had mild MATERIALS AND METHODS ovulatory problems (those which responded readily with ovulation to clomiphene citrate therapy), Information on 107 patients undergoing surgery five had leiomyomas, and two had intrauterine from 1966 to 1970 (group I) was published in 1973. 1 adhesions. In group II, 13% of patients had mild A similar report on 206 patients treated from De- ovulatory problems, nine had leiomyomas, three cember 1970 to December 1977 has recently ap- had septate uteri, and one had intrauterine adhepeared in Fertility and Sterility.2 The report on sions. group I excluded patients whose husbands had in- Three surgeons, including the author, treated adequate semen and those women lost to follow-up the patients in group I. Those in group II were in the 1st year. For purposes of comparison in this treated solely by the author. In both groups, the study, 42 of the 206 patients were excluded be- severity of endometriosis was designated as cause of a male infertility factor, and 26 were ex- "mild," "moderate," or "severe" according to a pubcluded because they were lost to follow-up in the lished classification. I, 10 The postoperative preg- 635

636 BU'ITRAM nancy rates were established for each group and the results were compared. Additionally, an attempt was made to evaluate the efficacy ofremoving, rather than repairing, diseased adnexa when the pathologic involvement was unilateral. Surgical Procedure. For both groups I and II, surgical procedures included exploratory laparotomy, excision or fulguration of endometrial implants, resection and plication of uterosacral ligaments, presacral neurectomy, uterine suspension, and, occasionally, appendectomy. Hysterosalpingography and dilatation and curettage with endoscopy (either culdoscopy or laparoscopy) preceded the laparotomy in all but a few cases. For reasons explained under "Discussion," the surgical technique used in treating group I was modified after 1970. Since that time suture materials have improved, but our technique has remained essentially unchanged. Current Surgical Techmque. As illustrated in Figure la, a 10-cm transverse incision is made just inside the pubic hairline 3 to 4 cm above the symphysis pubis. A 2-0 Vicryl stay suture is placed just below the insertion of the uterosacral ligaments into the lower cervical segment of the uterus (Fig. 1B). Similar 2-0 Vicryl stay sutures FIG. 1. Abdominal incision and placement of stay sutures. Excision of ovarian endometriomas or unilateral salpingooophorectoniy. December 1979 FIG. 2. Resection and plication of uterosacral ligaments. are then placed on each uterosacral ligament approximately 3 cm from its insertion into the lower cervical segment of the uterus (Fig. 1B). Such action affords adequate exposure of the pelvic pathology. If indicated, removal of an adnexum or an endometrioma is performed at this time to provide additional space in the pelvic cavity early in the procedure (Fig. 2G). If an ovarian endometrioma is removed, 6-0 Dexon sutures are placed as stay sutures (Fig. lb). After the endometrioma is sharply excised, subcapsular interrupted 00 Vicryl figure-eight sutures are used to provide hemostasis in the ovarian cortex (Fig. 1, C and D). The cut surfaces of the ovary are gently inverted with a 6-0 Dexon running suture used to imbricate the edges (Fig. 1E). If the adnexa are to be removed, the infundibulopelvic ligament is identified, cut, and ligated. The tube and ovary are excised from the mesosalpinx and utero-ovarian ligament; hemostasis is achieved with 00 Vicryl suture figure-eight stitches (Fig. 1F). Reperitonization of the infundibulopel vic stump is accomplished with sutures of 00 Vicryl (Fig. 2G). The uterosacral ligaments are then excised from the stay suture to the point of insertion into the lower cervical segment of the uterus (Fig. 2H). As much endometriotic tissue as possible is removed during the resection process. However, care is required because excess lateral extension of the excision may injure the ureter or uterine blood vessels. Excess medial extension can conceivably injure

Vol. 32, No.6 SURGICAL TREATMENT OF ENDOMETRIOSIS 637 Following presacral neurectomy, attention is redirected to the posterior cul-de-sac. With a no. 1 silk suture, the uterosacral ligaments are rejoined to the lower cervical segment of the uterus (Fig. 2K). The suture runs in a medial to lateral direction, picks up the end of one uterosacral ligament, then moves through the lower uterine segment just above the initial stay suture before moving back in a lateral to medial direction through the end of the opposite uterosacral ligament stump (Fig. 2L). The suture knot will thus be hidden under the uterosacral ligaments. Further plication of the uterosacral ligaments is performed with 3-0 silk suture, and, again, the knot is left under the ligaments. This technique frequently leaves an opening lateral to the point where the ligaments have been stitched to the lower uterine segment; it is closed with interrupted 3-0 black silk suture (Fig. 2M). The reapposition and plication of the uterosacral ligaments produces a "shelf' upon which the adnexa can rest, thereby FIG. 3. Presacral neurectomy. the bowel. A figure-eight suture of 2-0 Vicryl frequently is needed for hemostasis near the lower uterine segment (Fig. 21). The uterosacral ligament stay suture is used to make a running lockstitch. The result is not only hemostasis and reperitonization, but also a bunching effect which shortens the uterosacral ligament (Fig. 2J). The presacral neurectomy can best be done before reapposition of the ligaments to the uterus. The peritoneum overlying the sacral promentory is incised about 3 cm, and 3-0 silk sutures are applied to the edges as stay sutures. Blunt dissection is used to isolate the presacral nerve plexus (Fig.3N). The lateral boundaries of dissection are carefully determined. The right ureter is visualized and forms the right lateral border of the dissection. The mesocolon and its vessels represent the left border of the dissection (Fig. 30). A 1-cm segment of the presacral nerve is excised and the ends ligated with no. 1 silk suture (Fig. 3P). Reperitonization is routinely performed with 2-0 Vicryl suture. The purpose of the presacral neurectomy is to alleviate dysmenorrhea. Although its role in enhancing the chances for conception is unknown, it has been used routinely by many surgeons as part of their conservative surgery in patients with endometriosis.4, 11 FIG. 4. Uterine suspension.

638 BU'ITRAM December 1979 red.ucing the chances of postoperative adhesions. If one adnexum has been removed, the stump of the fallopian tube and the utero-ovarian ligament must be reperitonized. The round ligament is sutured to the uterus with 3-0 silk suture as demonstrated in Figure 4, Q, R, S, and T. Such a maneuver provides not onlyreperitonization but uterine suspension as well. The opposite round ligament is then triplicated with 3-0 silk, as demonstrated in Figure 4T. When neither adnexum has been removed, bilateral triplication of the round ligaments or, sometimes, a modified Guilliam uterine suspension is performed. In the latter procedure, the round ligaments are brought through the peritoneum just lateral to the rectus muscles and sutured with 3-0 silk to the undersurface of the rectus fascia as demonstrated. in Figure 4, U and V. The purpose of the uterine suspension by plication of the uterosacral ligaments or a modified. Guilliam procedure is twofold. Suspension places the cervical os in the posterior area of the vaginal vault, thus increasing its exposure to semen. It brings the uterus with the adnexa out of the posterior cul-de-sac and thus reduces the susceptibility ofthe ovaries and tubes to postoperative adhesions. Theoretically, it should also aid in preventing futher reflux menstruation. Although its value in enhancing fertility has not been documented, uterine suspension has been performed. routinely during conservative surgery in patients with endometriosis. 4,11 Appendectomy. Incidental appendectomy seems inadvisable when an ovarian endometrioma is removed, since susceptibility to bacterial contamination may be increased in a traumatized ovary. When the ovarian capsule is not incised and the appendix is readily accessible, appendectomy is performed. If not removed, the appendix is examined for signs of endometriotic involvement. In 2 of 56 patients in group II, incidental appendectomy revealed endometriosis involving the appendix. An overriding concern is to protect as much as possible against postoperative adhesions. Care is taken to limit trauma. Raw exposed areas must be reperitonized and good hemostasis obtained. Irrigation throughout the operative procedure is necessary to remove blood and to prevent drying of tissue. Clearly, the procedure described can offer only basic guidelines. Each case must be managed "individually," and the operaton frequently tests the surgeon's initiative and ingenuity. TABLE 1. Comparison of Postoperative Pregnancy Rates in Groups I and II Pregnancy rate Extent of disease Group No. of patients No. % Mild I 8 6 75% II 61 51 84% Moderate I 60 30 50% II 32 24 75% Severe I 39 13 33% II 45 25 56% RESULTS Of the 107 patients in group I, 8 had mild, 60 had moderate, and 39 had severe endometriosis. Of the 138 patients in group II, 61 patients had mild, 32 had moderate, and 45 had severe endometriosis. As the numbers suggest, surgery for "mild" endometriosis has been employed with increasing frequency since 1970. Table 1 indicates the pregnancy rates for patients with mild, moderate, or severe endometriosis for groups I and II. In each category the pregnancy rate was higher in group II, the greatest difference occurring in patients with moderate endometriosis rp < 0.05, xr = 4.95). Of patients with mild endometriosis, 75% in group I and 84% in group II conceived.. For patients with moderate endometriosis the postoperative pregnancy rates were 50% (group I) and 75% (group II). When endometriosis was severe, the postoperative pregnancy rates were 33% (group I) and 56% (group II) (P < 0.10, xi = 3.10). Table 2 shows the postoperative pregnancy rates for the 20 patients in group II from whom "diseased." adnexa were removed and for the 8 in whom the adnexa were "repaired" by excision of endometriotic tissue and/or lysis of adhesions. In 8 of 11 patients with moderate endometriosis, the procedure included unilateral salpingo-oophorectomy rather than repair of the adnexa; 6 (75%) of the women conceived. Of the three in whom conservation was attempted, one (33%) conceived. Ofthe 17 patients with severe endometriosis and unilateral adnexal involvement, 12 had unilateral salpingooophorectomy and 9 (75%) became pregnant. Of the 5 whose adnexa were "repaired," 2 (40%) conceived. The information was not available for group I, but the 138 patients in group II have been followed an average of 45.4 months. A total of six patients (none with mild, two with moderate, and four with severe disease) have required total abdominal hysterectomy and oophorectomy for recurrent

Vol. 32, No. 6 SURGICAL TREATMENT OF ENDOMETRIOSIS 639 Extent of disease TABLE 2. Postoperative Pregnancy Rates for Patients in Group II with Unilateral Pathology No. of patients Unilateral salpingo-oophorectomy Pregnant Moderate 11 6 (75.0%) Severe 17 9 (75%) Conservation of adnexa Not pregnant Pregnant Not pregnant 2 1 (33.3%) 2 3 2 (40%) 3 symptoms. More detailed analysis of recurrence rates is in progress. DISCUSSION Two factors. influenced the decision to modify our surgical procedure. The first was a study, initiated in 1970, of patients who had undergone bilateral wedge resection for polycystic ovarian disease.12 Of 173 patients, 59 (34%) subsequently developed significant ovarian adhesions. Prior to that time an attempt usually was made to repair a diseased ovary even if it had significant endometriotic involvement and/or adhesions. This evidence of the vulnerability of the ovaries to development of postoperative adhesions and the similarity of the traumatic effect on the ovary ofwedge resection ~d ovarian "repair" suggested the possibility of further compromising fertility. Therefore, after 1970, we began, with increasing frequency, to remove diseased adnexa when the contralateral adnexa were normal. Table 2 shows postoperati~e pregnancy rates for patients in group II with unilateral pathology. Although the number of patients was small, the information obtained is consistent with our speculations. The current technique for dealing with bilateral disease involves careful imj>rication of raw ovarian surfaces and the use of new suture materials with decreased reactivity. These improvements should reduce the risk of ovarian adhesions. A second factor in changing our approach was the observation that many patients conceived after surgery even when we had been unable to excise or cauterize all of the endometriosis. Our experience suggested the acceptability of a less aggresf!ive surgical approach. Thus, in group II, endometrial implants which could be removed with proper reperitonization were excised, but complete extirpation was not attempted when the result might have been to damage vital organs such as the ureter, bladder, bowel, or important blood vessels- or tojeopardize fertility by causing postoperative ovarian and/or tubal adhesions. Still, the goal of the surgery was to remove as much endometriosis as possible. Studies are currentlybeing conducted to determine the effective- ness of medical suppression (danazol) alone and of preoperative medical suppression in infertile patients with endometriosis. The results of this study (Tables 1 and 2) suggest that the less aggressive approach to removal of implants and the more aggressive approach to unilateral adnexal disease increase the likelihood of conception, particularly in patients with moderate and severe endometriosis. Results differed least in patients with mild endometriosis. Perhaps because of earlier diagnosis in recent years, group II contained more patients with mild endometriosis than did group- I. However, the proportionate number who conceived was similar. This is not surprising since extensive dissection or cauterization (used in group I and avoided in group ll) was not required for mild endometriosis in either group. Whether the endometriosis was mild, moderate, or severe, the more recent surgical approach resulted in a higher pregnancy rate. It may be argued that failute to remove all implants merely postpones a hysterectomy or oophorectomy. However, this concern must be weighed against the threat to fertility when, indeed, conception is the immediate goal. Although the number of patients in each category is relatively small, the data suggest that postoperative pregnancy rates can be improved by aggressive therapy when unilateral adnexal disease is present and by restt'aint when determining how much ectopic endometrium to remove. Acknowledgments. The author wishes to express his appreciation to Carolyn Schum for her editorial assistance and to Susarine Ward for her help in gathering data.. REFERENCES 1. Acosta AA, Buttram VC, Jr, Besch PK, Malinak LR, Franklin RR, Vanderheyden JD: A proposed classification of pelvic endometriosis. Obstet Gynecol 42: 19, 1973 2. Buttram VC Jr: Conservative surgery for endometriosis in the infertile female: a Study of 206 patients with implications for both medical and surgical therapy. Fertil Steril 31:117,1979 3. Beecham CT: Classification of endometriosis. Obstet Gynecol 28:437, 1966 4. Rogers SF, Jacobs WM: Infertility and endometriosis: conservative surgical treatment. Fertil Steril19:529, 1968 5. Grant A: Infertility surgery' of the oviduct. Fertil Steril 22:496, 1971

640 BU'ITRAM December 1979 6. Spangler DB, Jones GS, Jones HW Jr: Infertility due to endometriosis: conservative surgical therapy. AmJ Obstet Gynecol 109:850, 1971 7. Ranney B: The management of endometriosis. In Controversy in Obstetrics and Gynecology, Second Edition, Edited by DE Reid, CD Christian. Philadelphia, WB Saunders Co, 1974, p 637 8. Kistner RW: Management of endometriosis in the infertile patient. Fertil Steril 26:1151, 1975 9. Sadigh H, Naples JD, Batt RE: Conservative surgery for endometriosis in the infertile couple. Obstet Gynecol 49:562, 1977 10. Buttram VC Jr: An expanded classification of endometriosis. Fertil Steril 30:240, 1978 11. Kistner RW, Patton GW Jr: Atlas of Infertility Surgery. Boston, Little, Brown and Co, 1975, p 189 12. Buttram VC Jr, Vaquero C: Post-ovarian wedge resection adhesive disease. Fertil Steril 26:874, 1975