JMSCR Vol||07||Issue||01||Page 510-515||January 2019

www.jmscr.igmpublication.org

ISSN (e)-2347-176x ISSN (p) 2455-0450

DOI: https://dx.doi.org/10.18535/jmscr/v7i1.85

Effectiveness of Laparoscopic Evaluation of Women with Previous Endometriosis for Improving Fertility Authors Dr Shamsun Nahar1 , Dr Dilshad Jahan2, Dr Naznin Akther3, Dr Sk. Farid Uddin Ahmed4, Dr Dilip Kumar Kundu5 1Professor & Head, Department of and Gynecology, Medical College, Khulna, 2Medical Officer (Private), Bangladesh 3Assistant Professor, Department of Obstetrics and Gynecology, Gazi Medical Collage Hospital, Khulna 4Associate Professor, Department of , Khulna Medical College, Khulna, Bangladesh 5Assistant Professor (Anesthesiology), Khulna Medical College, Khulna, Bangladesh *Corresponding Author Prof. Dr Shamsun Nahar Email: [email protected], Mobile # +8801711430888 Abstract Background: Endometriosis is a common and important health problem of women. This exact prevalence is unknown because surgery is required for it’s diagnosis. Endometriosis is more prevalent in the setting of infertility, with proper patient selection, a meticulously preformed laparoscopic, surgery is an excellent option that provides these patients to achieve repeated future pregnancies. Objective: Laparoscopic evaluation of previous open or laparoscopy surgery in women with all stage of endometriosis for improving fertility. Methods: Khulna medical college (KMC) and Victory endoscopic center based cross sectional descriptive study was performed in 2008 – 2016 in 200 cases for laparoscopic assessment and management of pelvic endometriosis with infertility. Criteria for performing laparoscopy was as follows: after initial laparoscopy or open surgery no improvement of pelvic pain, no improvement of fertility or no improvement of dysmenorhoea, dyspareunia and/or recurrence of chocolate cyst. Exclusion criteria’s were age above 40 years and Low AMH or ovarian reserve. Results: Within 200 cases, the age ranges from 25 – 40 years and period of infertility less then 3 years about 39% and more than 61%. Primary infertility was 85% and secondly infertility was 15%. Within 200 cases open surgery were 109 and laparoscopy were 91 cases and the documentation of previous were stage I endometriosis, 5.5%, stage – II 26.5%, stage III 33% and stage – IV 19.5%, documentation was lost in 15.5%. The surgeries which we had done reconstinction of pelvic and cystectomy but 8 patients were quired total abdominal hysterectomy and bilateral salphingeatomy due to frozen pelvis. 11 patient’s were referred to IVF and ET centre. Within these cases our achieved pregnancy rate was about 31% & rest are under observation. Conclusion: Relaparoscopy gives beneficial result if in young patient with good ovarian reserve. IVF treatment is definitely a suitable option for older patients and after 1st time surgery. But exclusion of age and ovarian reserve, 2nd time laparoscopic management is beneficial where limited facilities for IVF and ET. Keywords: Previous endometriosis surgery, laparoscopy, infertility.

Dr Shamsun Nahar et al JMSCR Volume 07 Issue 01 January 2019 Page 510

JMSCR Vol||07||Issue||01||Page 510-515||January 2019

Introduction factors affecting the spontaneous pregnancy, who Endometriosis is a benign disease of genital tract had done previous laparoscopy or open surgery in which abnormal growths of tissue histologically for management of endometriosis related resembling the endometriotic like tissue, infertility. consisting of glands and stroma found outside the endometrium. Although implanted ectopically, Materials and Methods this tissue presents histopathological and This was a retrospective cross sectional study was physiological responses that are similar to the conducted in Victory Endoscopic Center and obs responses of the endometrium. Incidence and & gynae department of KMCH. We selected 200 Prevalence are increasing significantly ranges cases for laparoscopic assessment and from 1～ 50%, 1～ 2% in general population, management of pelvic endometriosis with 30～ 50% in Infertile women, typically diagnosed infertility from the period of January 2008 – 2016, in women within 25-35 years age1,2. Diagnosed in who had not achieved pregnancy within 3 years approximately 45% of women undergoing after initial laparoscopy surgery due to pelvic laparoscopy in infertility & 35% with complaint endometriosis or endometrioma. The collated data of chronic pelvic pain. Family history increases included age, parity, history of infertility, mode of risk ten-fold & significant cause of morbidity. It’s surgery and subsequent fertility for all a “Disease of theories”; definitive cause or causes endometriosis with infertility patient’s. remain under debate, though associations with Criteria for performing laparoscopy was as number of hereditary, environmental, genetic, and follows: after initial laparoscopy or open surgery, menstrual characteristics exists. The diagnostic no improvement of pelvic pain, no improvement hypothesis of endometriosis is based on the of fertility no improvement of dysmenorhoea or clinical history, along with the results from dyspareunia and requrrence of chocolate cyst. gynecological examinations, laboratory tests and The patient should be reassessed clinically and by transvaginal ultrasound. Diagnosis by means of investigations that was transvaginal sonography laparoscopy, which is considered the gold scan, which helped to determined ovarian reserve, standard, some clinical characteristics, the number of antral follicles or follicular maturation, physical examination itself, laboratory test results sono tenderness, pelvic mass or blood in pelvis. and evidence from imaging examinations may Assessment of CA 125 level, taking laparoscopy suggest the diagnosis. The greatest difficulty lies biopsy form endometrial lesion. After initial in diagnosing minimal and mild lesions. In these laparoscopy or open surgery AMH test had done cases, the ideal access for confirmation is always for detection of poor ovarian reserve in suspected laparoscopic, since the complementary cases. examinations available do not offer the necessary Exclusion criteria’s were age above 40 years and specificity. The Chinese guidelines for the Low AMH or ovarian reserve. Under general diagnosis and treatment of endometriosis-related anesthesia pneumo peritoneum was made by CO2. infertility allow couples to have a period of about After introduction of telescope total assessment of 12months for potential spontaneously conception pelvic cavity was done followed by adhesiolysis after surgery before being offered IVF-ET, and restoration of pelvic anatomy, chocolate especially in younger women with minimal or cystectomy and tubal patcncy test. After surgery, mild endometriosis.3 The endometriosis fertility the patient’s were advised to actively attempt to index (EFI) has a predictive value for pregnancy conceive, either naturally or using ovulation after surgery. In vitro fertilization and embryo inducing drugs or with IVF-ET depends upon to transfer (IVF-ET) is a good treatment of surgical correction and ovarian reserve. infertility. This study aimed to reassessment the

Dr Shamsun Nahar et al JMSCR Volume 07 Issue 01 January 2019 Page 511

JMSCR Vol||07||Issue||01||Page 510-515||January 2019

Results 115 We had done 200 cases of laparoscopic surgery 109 110 from the period of January 2008 to January 2016, 105 in victory endoscopic centre and KMC, Who had Open Surgery not achieved pregnancy within 3 years after initial 100 open / laparoscopic surgery due to pelvic 95 91 Laparoscopic Surgery endometriosis or endometrioma. After completion 90 of laparoscopic surgery in different stage of 85 disease, all cases were follow up at least 1 year. 80 Age ranges of this patients were 25-40 years. Table – 1 presented the patient age, period of Figure1: initial open and laparoscopic surgery infertility and history of previous pregnancy. Within these 200 cases open surgeries were 109 The following Figure-2 showing the findings of and laparoscopic surgeries were 91 cases, showing initial laparoscopy /open – surgery for in figer I. Initial laparoscopy / open - surgery for endometriosis Endometriosis Stage I - 11(5.5%), Stage ll - 53 70 66 (26.5%) Stage lll - 66 (33%), Stage IV - 39 60 53 Stage 1 (19.5%) Inadequate or no documentation - 31 50 (15.5%), showing in figer – II. Again laparoscopic 39 Stage 2 40 33 evaluation was done in 200 cases and findings Stage 3 30 was plotted in table – II. Table – III was presented Stage 4 20 11 the surgery which we had done. Inadequate Table-1 Characteristics of the women included in 10 the study (n-200) 0

A. Figure-2: Initial laparoscopy /open – surgery for Characteristics Values endometriosis Age (year) (20-38 years) > 35 4% Laparoscopic findings showing in table– 2 30 – 35 46% 25 – 29 43% Table-2: Laparoscopic findings 20 – 24 7% Normal pelvic anatomy 17 (8.5%) B. Infertility length in year. Mild endometriosis 19 (9.5%) < 3 years 39% Unilateral & bilateral 25(12.5%) & 48(24%) > 3 years 61% adhesion respectively C. Previous Pregnancy Unilateral & bilateral 46 (23%), 20 (10%), Yes 15% endometrioma No 85% Short tube , tubal adhesion 17 (8.5%). and fimbrial agglutination

The following Figure-1 showing number of initial The surgeries which had done showing in table–3 open and laparoscopic surgery Table-3: Surgeries done Open the blocked tubes and/ or 92 cases restore the normal pelvic anatomy 17 One Tube 6 Both 85 Adhesiolysis Cystectomy and reconstruction 70 cases. of ovary Normal findings were 17 cases. Conversion to laparatomy 8 cases. Dr Shamsun Nahar et al JMSCR Volume 07 Issue 01 January 2019 Page 512

JMSCR Vol||07||Issue||01||Page 510-515||January 2019

Conversion from laparoscopy to laparatomy When the uterine ligaments are involved, followed by total abdominal hysterectomy and especially the uterosacral ligaments, thickening of bilateral salpingophrectomy were in 8, due to these structures occurs due to endometriotic frozen pelvic, adenomyosis and hydrosalpinx. One nodule formation, which tenders the ligaments. case had developed pelvic collection after The standard of reference for the diagnosis and laparoscopic which was drained by colpotopy, staging of endometriosis is laparoscopy but another one was directly trocar injury to the small sometimes the presence of endometriosis is intestine due to previous midline incision with observed by overlying dense adhesion, if carful dense intestinal adhesion. Advice for IVF and ET dissection is performed4. Serum CA-125, MR in bilateral blocked tube in 11 cases. After imaging is helpful for in patients with known laparoscopic surgery, clomiphene / letrol was used endometriosis who present with recurrent pain, in 168 cases. Within one to three year follow up, MRI helps to visualize laparoscopy blind spots 59 cases achieved pregnancy, abortion 2, 11 beneath dense adhesions and at extra peritoneal patients were advised for assisted reproduction sites such as the rectum, the vagina or within the and rest are under observation. bladder.5,6 Options for endometriosis infertily are surgery, IVF-ET, Oocyte donation, Oocyte Discussion cryopreservation before surgery. The aim of this Endometriosis is usually a multifocal progressive surgery is to 1. destroy or remove areas of disease tends to come back after treatment and endometriosis 2. destroy or remove ovarian lasts as long as there is ovarian function, that is endometriotic cysts, by cutting away or excising until menopauses. Therefore, prompt definitive the cyst wall (capsule) or opening the cyst, diagnosis and staging are extremely important for draining the chocolate fluid and destroying the lifelong treatment, recurrence prevention and capsule 3. divide adhesions to mace free tissues fertility improvment. The first grossly for improve fertility. The surgeon should also be recognizable lesions are blister like blebs 2-3 mm proposed to reseal endometiotic lesions that may in diameter on the surfaces of target organs. Over involve other organs such as the bowel or bladder. time, these blebs assume the characteristic powder Appendiectomy should also be performed if there burn” appearance produced by a collection of any adhesion or if endometriosis involves the hemorrhagic spots and bluish-red nodules or appendix. Currently, the main choice for the patches. The lesions may become cystic, but the diagnosis and treatment of endometriosis is cysts do not enlarge except in the ovary. As the laparoscopic surgery.6 For infertile women with disease progresses, the endometriotic sites may endometriosis as the only identifiable infertility become fibrotic, distorting the affected organ and factor, operative laparoscopy can improve forming adhesions with the surrounding pregnancy rates (PRs) in all stages.7 For women structures. The ovaries may be affected in two with minimal-to-mild endometriosis, operative ways. Small implants of endometrial tissue may laparoscopy is more effective than diagnostic cause paraovarian scarring and adhesions, or they laparoscopy in improving the pregnancy rate.7,8,9 may evolve into endometriomas or chocolate For women with moderate and severe cysts. Endometriomas are moderately thin-walled endometriosis, the spontaneous PR after cysts containing dark, semisolid, sticky material laparoscopic surgery is much higher compared that represents hemorrhage within the lumen of with those treated by expectant management.10 the cyst. Although the chocolate cyst is highly The conception after surgery was 59% (4), which suggestive of endometriosis, hemorrhage within a reconfirmed the effectiveness of laparoscopic corpus luteum cyst, a follicular cyst, or even a surgery. There 8 patients were required complete neoplastic cyst can have a similar appearance. removal of uterus and both ovaries by laparatomy,

Dr Shamsun Nahar et al JMSCR Volume 07 Issue 01 January 2019 Page 513

JMSCR Vol||07||Issue||01||Page 510-515||January 2019

due to destruction of total anatomy by dense the ovarian reserve of a single ovary, concluded adhesion associated with adenomyosis. Success the ovarian reserve evaluated with AFC was not rates of laparoscopy surgery are reported and significantly impaired by surgical excision of the studies suggest a 62.57% improvement or ovarian endometrioma when it was performed regulation of pain at 6 months, with 55% still with the stripping technique.16 another study improved at 12 months. reported a nine-month cumulative pregnancy rate The recurrence rate of endometriosis is of 24.4% in 18 women undergoing second surgery unpredictable, but is generally reported to be in for moderate or severe endometriosis (Stage III or the range of 5-20% per year11. Women wishing to IV) and a pregnancy rate of 33.3% and 69.6% 17 get pregnant should start trying as soon as but in our group 31% achieved pregnancy and rest possible after surgery. Sometime recurrence may are under observation. Major disadvantages of be related to incomplete removal or destruction of surgery are cost, morbidity, and longer time to the disease or if endometriosis is severe and conception. IVF treatment is definitely a suitable affecting organs such as bowel, it may not always option for older patients, and there are no scope be possible to remove all of the endometriosis for improving by using ovulation induction or during one laparoscopy. The cysts are attached to intrauterine insemination (IUI) the other structures by plaques of endometriosis, the plaques should be removed with cyst at the Conclusion same time, otherwise it may confine and caring Recurrence of pelvic endometriosis after surgery pain and adhesions. Detection of recurrence is is common in reproductive period. Diagnosis is suspected on the women history of very painful dependent on the clinical consideration of the menstrual cycle, painful intercourse or frozen possibility of the disease, physical examination pelvis by per vaginal examination or ultrasound and a good reception of medical history associated finding, CA-125 level or MR imaging. with TV scan, MRI and histopathology Before going to invasive procedure observed examination. Again laparoscopic evaluation is ovarian reserve carefully. Those have a low AMH beneficial and facilitated the way of natural and age above > 40 years should consider here for fertility but elderly patients need to careful IVF and ET with donor ovum. Our selected evaluation about ovarian reserve and better option patients were 200 but about 31% women missed for IVF and ET. This study could not only their previous surgical documents. evaluate the optimal time to propose IVF The impact of surgery for ovarian endometriomas treatment after surgery, but also reassessment and on ovarian reserve has been a subject of great management – definitely improve fertility after interest. Poor response to ovarian stimulation for proper selection of patients. Re-evaluation assisted reproduction has been reported in patients information can be done by patients and physicals who had undergone excision of ovarian as a reference to determine when to adopt IVF- endometrioma.12 A younger age at menopause and ET. premature ovarian failure has also been reported respectively13. Typically, AMH has been used as References the marker for reduced ovarian reserve in these 1. Houston DE. Evidence for the risk of pelvic studies in two systematic views performed a meta- endometriosis by age, race and analysis to investigate the impact of surgery for socioeconomic status. Epidemiol Rev. endometriomas on ovarian reserve as determined 1984;6:167-91. by serum anti-müllerian hormone (AMH).14, 15 2. Jansen RP, Russell P. Nonpigmented Antral follicle is a reliable marker for ovarian endometriosis: clinical, laparoscopic, and reserve and has the advantage of correlating with

Dr Shamsun Nahar et al JMSCR Volume 07 Issue 01 January 2019 Page 514

JMSCR Vol||07||Issue||01||Page 510-515||January 2019

pathologic definition. Am J Obstet Gynecol. Reproductive performance, pain recurrence 1986; 155(6):1154-9. and disease relapse after conservative 3. Cooperative Group of Endometriosis, surgical treatment for endometriosis: The Chinese Society of Obstetrics and predictive value of the current classification Gynecology, Chinese Medical Association. system. Hum Reprod. 2006;21:2679–85. Guideline for the diagnosis and treatment of doi: 10.1093/humrep/del230. [PubMed] endometriosis (in Chinese) Chin J Obstetr 11. Winkel CA. Evaluation and management of Gynecol. 2015;50:161-9. Doi: women with endometriosis. Obstet Gynecol 10.3760/cma.j.issn.0529-567x.2015.03.001. 2003;102: 397- 408 [PubMed] 12. Hart RJ, Hickey M, Maouris P, et al. 4. Anderson MC. Endometriosis. In: Symmeo Excisional surgery versus ablative surgery WSTC, ed. Systemic . 3rd ed, vol for ovarian endometriomata. Cochrane 6. New York, NY: Churchill Livingstone, Database Syst Rev. 2008;(CD004992) 1991; 263-275. [PubMed] 5. Dan H, Limin F. Laparoscopic ovarian 13. Coccia ME, Rizzello F, Mariani G, et al. cystectomy versus fenestration/coagulation Impact of endometriosis on in vitro or laser vaporization for the treatment of fertilization and embryo transfer cycles in endometriomas: A meta-analysis of young women: a stage-dependent randomized controlled trials. Gynecol interference. Acta Obstet Gynecol Scand. Obstet Invest. 2013;76:75–82. doi: 2011;90:1232–1238. [PubMed] 10.1159/000351165. [PubMed] 14. Raffi F, Metwally M, Amer S. The impact 6. Togahi K, Niohiomra K, Kimula I etal- of excision of ovarian endometrioma on Endometrial cyst: diagrosis of MR imaging. ovarian reserve: a systematic review and 1991; 180:73-78. meta-analysis. J Clin Endocrinol Metab. 7. Jacobson TZ, Duffy JM, Barlow D, 2012;97:3146–3154. [PubMed] Farquhar C, Koninckx PR, Olive D. 15. Somigliana E, Benaglia L, Vigano P, et al. Laparoscopic surgery for subfertility Surgical measures for endometriosis-related associated with endometriosis. Cochrane infertility: a plea for research. Placenta. Database Syst Rev. 2010;1:CD001398. doi: 2011;32(Suppl. 3):S238–S242. [PubMed] 10.1002/14651858. [PubMed] 16. Muzii L, Di Tucci C, Di Feliciantonio M, et 8. Practice Committee of the American al. The effect of surgery for endometrioma Society for Reproductive . on ovarian reserve evaluated by antral Endometriosis and infertility: A committee follicle count: a systematic review and opinion. Fertil Steril. 2012;98:1400–6. doi: meta-analysis. Hum Reprod. 2014;29:2190– 10.1016/j.fertnstert.2012.05.031. [PubMed] 2198. [PubMed] 9. Dunselman GA, Vermeulen N, Becker C, 17. Pagidas K, Falcone T, Hemmings R, et al. Calhaz-Jorge C, D’Hooghe T, De Bie B, et Comparison of reoperation for moderate al. ESHRE guideline: Management of (stage III) and severe (stage IV) women with endometriosis. Hum Reprod. endometriosis-related infertility with in vitro 2014;29:400–12. doi: fertilization-embryo transfer. Fertil Steril. 10.1093/humrep/det457. [PubMed] 1996;65:791–795. [PubMed] 10. Vercellini P, Fedele L, Aimi G, De Giorgi O, Consonni D, Crosignani PG.

Dr Shamsun Nahar et al JMSCR Volume 07 Issue 01 January 2019 Page 515