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-