Deeply Infiltrating Endometriosis and the Infertile Horse Rainbow
Abstract: Deeply infiltrating endometriosis (DIE) can lead to infertility by an unknown mechanism. In DIE-related infertility, drug therapy alone does not improve pregnancy rates but delays conception. Two cycles of in vitro fertilization-embryo transfer are recommended for women with infertility due to DIE, but surgery is recommended when it is not effective. Wang Wen, Department of Obstetrics and Gynecology, Anyang Maternal and Child Health Hospital
Keywords: endometriosis, deep infiltrative type; infertility
C.I.C.: R711. 71 Document symbol: C
Abstract: Deep-infiltration endometriosis( DIE) cancause infertility, but the pathogenesis is unclear. Evi-dence to date indicates that medical therapy is not ofbenefit for DIE associated infertility but surgery canbe beneficial. However, for those who are DIE asso-ciatedinfertility, undergoing ommended. However, for those who are DIE asso- ciatedinfertility, undergoing two cycles of endometriosis, deep-infiltration; infertility However, for those who are DIE asso-ciatedinfertility, undergoing two cycles of IVF / ICSIbefore deciding on further surgical treatment is The endometriosis (DIE) refers to endometriosis lesions infiltrating to a depth of 5 mm. DIE can cause pain and infertility. The most frequent site of DIE is the sacral uterine ligament and the depth of infiltration is up to 5 mm. The deep-infiltration endome- triosis (DIE) refers to endometriosis of the uterine rectum and the rectovaginal septum [2], while DIE lesions can also involve the intestine. DIE can lead to severe symptoms in the digestive and urinary systems due to the presence of the ureter, ureter and bladder. 1 Mechanisms of infertility caused by DIE The prevalence of endometriosis (endometriosis) is 7% in women. The incidence of DIE has not been exactly reported yet, but with the advancement of medical care, the incidence of DIE has been increasing. The diagnosis rate has been increasing year by year [3]. In patients with infertility In endometriosis, the incidence of endometriosis is as high as 35%-50% and 30%-50%. The prevalence of endometriosis is 7% in women, and there is no certainty about the incidence of DIE. 50% of patients with endometriosis have impaired fertility [4-5]. Studies have shown that the incidence of DIE is 7% in women. The incidence of infertility associated with DIE is related to the age, ovarian reserve function and endometriosis of the patient. There is no specific study on DIE guidance [4-5]. The specific mechanism of infertility in patients with endometriosis, however, is not known because 93.5% of DIE patients have a combination of ovarian Endometriosis cysts, peritoneal endometriosis lesions, or uterine rectal fossa sealing have been shown to be associated with infertility. Therefore, the combination of folliculogenesis disorders, enhanced oxidative stress, immune disorders, and endometriosis in patients with DIE with concomitant ovarian damage [6]. However, there is no specific study on the specific mechanism of infertility caused by DIE, but it has been shown to be due to altered function, abnormal hormonal environment, reduced endometrial tolerance, extensive pelvic and abdominal lesions or rectal disease. However, the combination of endometriosis cysts, peritoneal endometriosis and endometrial hetero-adhesions that affect tubal egg collection in 93.5% of DIE patients are all involved in DIE-related infertility. 2 Treatment of DIE-related infertility How to manage DIE patients of childbearing age, especially when they are in the same In case of combined infertility, whether to consider conservative drug treatment or surgical treatment should be considered. In vitro fertiliza- tion (IVF) is the most common method of treatment for DIE, or in vitro fertiliza- tion is the direct choice. tion- embryo transfer (IVF-ET) to facilitate pregnancy has been a problem for clinicians. To date, most studies have concluded that DIE-associated tion-embryo transfer (TET) is the most common form of treatment.
In infertility, pharmacological treatment alone does not improve the chances of pregnancy [7]. Hughes [8] included the results of a Cochrane systematic review of 24 randomized controlled studies. To date, most studies have shown that ovulation suppression medications are more effective than placebo and expectant therapy groups. Treatment (including danazol, GnRHa, progestins, oral contraceptives) does not improve pregnancy. pregnancy outcomes in patients with endometriosis, including DIE, would instead In addition, the side effects of these drugs themselves have a negative impact on fertility. The results of the Co chrane systematic evaluation showed that ovulation-suppressing drugs (including danazol, GnRHa, progestin) were damaging and costly compared to the placebo and expectant groups. Therefore, for patients with DIE with combined infertility, no Medication alone is recommended. Studies have shown that surgical treatment has a damaging effect on almost all types of The side effects of these drugs are effective in endometriosis-related infertility. surgery can remove the visible The surgical treatment of endometriotic lesions, removal of pelvic inflammatory mediators, and restoration of normal pelvic anatomy is essential for almost all types of endometriosis combined with infertility. The surgical procedure can be effective in removing the visible tissue, impeding disease progression, relieving symptoms such as painful intercourse, and improving the quality of sexual life. This improves the postoperative pregnancy rate [9-11]. In cases of infertility without other causes, surgery can In patients with DIE involving only the sacral ligament, complete surgical excision of the disease is possible. The procedure can remove visible endometriosis, remove pelvic inflammatory media, restore pelvic anatomy, impede disease progression, and relieve painful intercourse, resulting in a spontaneous pregnancy rate of 46.7% after surgery [12]. Intestinal involvement is one of the most aggressive manifestations of DIE, with an incidence of In the absence of other causes of infertility, only the involvement of 3% to 37% [13]. The endometriosis lesion can directly invade the intestinal wall, resulting in a total pregnancy rate of 46.7% [9]. In patients with DIE without other causes of infertility and with only involvement of the sacral ligament, complete surgical excision of the lesion may result in a natural postoperative expectancy, with involvement of the intestinal lumen and infiltration of the surrounding tissue. The most frequent sites are the rectum, sigmoid colon, and the anus. The most aggressive form of DIE is intestinal involvement. In infertile patients with DIE lesions invading the intestinal canal, it is the choice of The choice of partial resection of the intestinal canal or only the surface lesions is controversial. The affected intestinal canal can include a wide area from the small intestine to the anus, but the most E After partial resection of the intestine, anastomotic fistulas, rectovaginal fistulas, intestinal perforations, and fistulas of the intestine may occur. The risk of serious complications, such as pelvic abscesses [14], is increased, and these complications The incidence of intestinal stenosis, whether the vaginal wall is opened during surgery, endometrial fistula, rectovaginal fistula, and rectovaginal septum are all important factors. The extent of ectopic infiltration and the operator’s experience are closely related. However, if only The risk of postoperative recurrence is increased when the surface lesion of the intestinal canal is removed [15], and the risk of recurrence is increased when ovulation is promoted. The risk of these complications is closely related to the location of the intestinal stricture, the possibility of progression of endometriosis during the procedure, and the development of severe excision [16]. The results of the current study have been combined for patients with severe pelvic pain, bowel In infertility patients with significant stricture and severe gastrointestinal symptoms, partial resection of the intestinal canal is required. Anastomosis is more beneficial than resection alone in improving postoperative pregnancy rates and reducing recurrence. However, for infertile patients with intestinal DIE without obvious abdominal pain symptoms, it is necessary to perform a partial resection of the intestine [17]. The risk of surgery should be fully weighed before making a decision. In terms of surgical approach, laparoscopic surgery is recommended, and the pregnancy rate after laparoscopy The rate of recurrence was significantly higher in the open surgery group [18]. This may be related to pelvic-abdominal adhesions after laparoscopy. However, in infertile patients with intestinal DIE without significant abdominal pain symptoms, the connection is less severe and has less impact on the function of the fallopian tubes and ovaries [19], while laparoscopic The rapid postoperative recovery means that pregnancy can be tried as soon as possible. Given the complexity of the procedure This may strongly suggest that patients with a diagnosis of DIE should be referred to a hospital with experience in the treatment of DIE [19]. In the case of the laparoscopic group, the pregnancy rate was significantly higher than that of the open group [18]. The surgical treatment of DIE is a complex and high-risk operation, so the preoperative rate is higher than that of open surgery. The assessment is crucial. A detailed preoperative investigation by an experienced clinician is required. In addition, gynecologic ultrasound, transrectal ultrasound and pelvic MRI should be performed to evaluate DIE. However, the use of GnRHa preoperatively may increase the risk of DIE. There is no definitive opinion on pregnancy rates after surgery. Theoretically, the preoperative use of GnRHa may reduce the inflammatory response and local vascularization, shrink the lesion, and make the procedure more effective. However, it is easier and less invasive for the operation, which is more conducive to complete resection of the lesion and less postoperative damage. The results of this study are summarized in the following table: (1) the formation of adhesions, thus contributing to an increase in the postoperative pregnancy rate [20]. However, the drug itself Theoretically, preoperative GnRHa may reduce inflammatory reactions and local side effects, high costs, and temporary suppression of endo-herpetic lesions, resulting in a lower rate of pregnancy. The inability to detect small lesions during surgery is also a problem that should not be ignored. It is noted that postoperative treatment with danazol or GnRHa has been shown to be more effective than expectant treatment in However, there is no difference in the side effects, high cost and temporary improvement of pregnancy rates in patients with endometriosis-related infertility (Class Ib evidence). [21]. Therefore, it is recommended that in patients with no other cause of infertility, postoperative In the absence of spontaneous conception six months to one year after surgery, there is no difference in the pregnancy rate between the two. The E SHRE guideline states that postoperative treatment with danazol or GnRH a is more effective than expectant treatment in improving the chances of pregnancy in patients with endometriosis-related infertility than expectant treatment with IVF-ET [22]. If the patient is older and has reduced ovarian reserve function, the In the absence of other abnormalities in the male partner’s routine semen analysis, early conception assistance is recommended. The results of the study are summarized below. Although a large number of studies have demonstrated that surgical removal of DIE lesions can improve the chances of self-assisted reproduction (assisted reproductive technology), it is not possible to achieve a pregnancy without the use of a surgical procedure. In addition to the pregnancy rate and ART pregnancy rate, the risk of the procedure itself and the risk of the ART technology (ART) have been studied. The development of assisted reproductive technology (ART) is the first choice for patients with DIE-related infertility. Of course, DIE, like other endometriosis, may reduce the risk of assisted reproductive technology. The success rate of ART has been shown to be high. The use of GnRHa for 3-6 months prior to assisted reproductive technology may improve the pregnancy rate. Ballester et al [23] found that, in addition to age, serum anti-Müllerian hormone, and the success rate of DIE-associated infertility, the success rate of the ART technique was higher.
Of course, DIE, like other endometriosis conditions, may also reduce the number of assisted conception techniques (AMH) levels, intracytoplasmic single sperm injection (ICSI) or IVF cycles. In addition, DIE also severely affects the success of ICSI or IVF and is a major factor in the success of ICSI. Ballester et al [23] found that in addition to age, serum anti-Mullerian or IVF clinical pregnancy rates were the most important factors, while years of infertility, body mass index (BMI), and the number of IVF cycles were the most important. (BMI), type of infertility (primary or secondary infertility) and the presence of coexisting ovarian chorioallantoic cells. In addition, DIE also significantly affects ICSI or IVF success, except for ICSI and IVF cycle number. They designed an intuitive and easy-to-use list of the results of the study (Figure 1). The positive predictive value for predicting the success rate of ICSI or IVF in patients with DIE can be used to predict the clinical pregnancy rate. The use of this list chart can guide the use of the ICSI chart (Figure 1) for the IVF. Based on these findings, they designed an intuitive and easy-to-use treatment option for infertile DIE patients. In patients with DIE combined with infertility, the positive predictive value can be used to predict the pregnancy rate. It is recommended that two cycles of ICSI or IVF be performed first, and if no pregnancy is achieved, then consideration can be given to performing the ICSI or IVF. The positive predictive value is 88.9% and the negative predictive value is 84.6%, which should be treated surgically. Figure 1: List of predicted clinical pregnancy rates in one ICSI or IVF cycle Darai et al [24]. The study also supports that in patients with a history of IVF failure, surgery may be considered. Surgical removal of the DIE lesion may significantly improve pregnancy rates. However, the results of the above study Only for patients presenting with infertility as the main symptom, but not for those with severe pain. The study by Darai et al [24] also showed that the rate of pregnancy is higher in other cases such as pain (dysmenorrhea, painful intercourse, etc.), gastrointestinal symptoms (blood in the stool, intestinal obstruction, etc.), etc. In patients with a history of IVF failure, surgical removal of the DIE lesion may significantly improve the outcome of the procedure, except in patients for whom surgery is indicated. 3 Conclusion DIE combined with infertility is a rare but very difficult clinical condition to manage. However, these findings are only applicable to patients who present with infertility as their primary symptom, but not to those who have severe pain (pain in the hands. In patients with severe pain (dysmenorrhea, painful intercourse), medication alone does not improve the pregnancy rate, but delays it.
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