What is your approach in the treatment of ovarian endometrioma?
Dr.Rasekh Jahromi (MD,Obstetrician & Gynecologist)
Jahrom university of medical sciences,Jahrom,Iran. Drrasekh@yahoo.com
)
Methods
Objectives
this clinical trial research evaluates 189 patients with
primary infertility during 5 years were operated due to
unresponsive to medical therapy. Women aged were 21-35
years. 17 (8.9%) patients who had ovarian endometriom
greater than 3cm, which underwent surgical Laparoscopy.
Ovarian endometriomas was diagnosed by vaginal
ultrasonography. Ovarian cysts are specified with a view of
round and relative thick-wall that is filled with echogenic fluid.
These cysts were persisted despite several menstrual cycles.
The patients were treated medical therapy with endometrioma
in size 3-5 cm for three months by combination of
contraceptive HD and Danazole(400mg per day). But, they
didn’t response. Hormonal assay (AMH, FSH) was done
previous operation that was in normal range. Therefore, it was
applied the technique of ovarian laparoscopic fenestration
and bipolar coagulation of the inner wall of the endometriotic
ovarian cyst in 9 to 10 points at 70 watt cutting power and
a 40 watt coagulating power setting and as the probe is
pushed into the capsule, electricity is activated for 3-4
seconds . At the end of ovarian drilling was cooled down by
irrigation using saline normal solution (500-1000cc). Then
treatment was performed with GnRH Agonist for three
months.when menstruation was started , induction of
ovulation was begun with clomiphene citrate, and other drugs
if need then followed monitoring by ultrasonography, when
follicular size were 18-20mm ,HCG was prescribed. The data
were analyzed by SPSS.
Endometriosis is defined as the presence
of
endometrial
glands
and
stroma
outside the endometrial cavity and
uterine musculature. The most common
site of endometriosis is pelvis, but
endometrotic implants may occur nearly
anywhere in the body. Endometriosis is a
common and serious gynecologic problem
in reproductive age women, who have
pelvic pain, dyspareunia, or infertility. The
goal of this research, using immediate
medical treatment after surgical procedure
to improve the fertility rate in ovarian
endometriomas.
ResuLt of fenestration and
coagulation of endometriomal
cyst
8
Results
endometrioma
200
8.95% 76.40%
59%
30%
23.50% 5.80%
The patients were followed up about 8 years.13 (76.4 %) patients from 17(8.95%)
patients with ovarian endometriomas who had clinical pregnancies rates after 18
months of operation and immediate medical therapy. 10 (58.8%) patients from 13
patients had term pregnancy. 3(30%) of 10 patients had stillbirth initially and their
second pregnancy was term. 3(30%) patients had 2 abortions without term
pregnancy. 4(23.5%) patients have not conception yet. One (5.8%) of them have
had recurrent endometriomal cyst .
Three laparoscopic techniques are present fo treatment of ovarian
endometriomas greater than 3 cm diameter: 1-Donnez and Brosens and
colleagues, were suggested three stages; 1- drainage of ovarian endometriomas
by laparoscopy 2-treatment with GnRH Agonist for three months 3- second
laparoscopy for remnant implants by laser vaporization. 2- Sutton and colleagues
suggested Laser vaporization of the cyst wall without any medical treatment
before surgery in ovarian endometriomas fewer than 10 cm in 1997.3-Canis and
Wattiez proposed Laparoscopic ovarian endometriomal cystectomy using the
stripping techniques. There is a new debate about determination of AMH levels
before and after surgery of endometriotic ovarian cyst and choosing the best
method to compare theAMH levels before and after surgery. This method has
several research centers including the Center of professor Dannez. It seems to be
the lowest rate AMH in the three stages of laparoscopic technique of professor
Dannez.In our study, following to stop the menstrual cycle after surgery for 3
months because the suppressor remnants of endometriotic lesions immediately
after laparoscopic surgery, response rates will be better and further in healthy
tissues. The fenestration and bipolar coagulation is carried out on the basis of
hormone levels; so the rate of follicle damage is reduced. Preservation of ovarian
blood supply is an important role in maintaining of follicular reserve. Therefore
the fertility outcome is much faster.
Conclusions
The application of ovarian laparoscopic fenestration and coagulation
of the inner wall of the endometriotic ovarian cyst and immediate
medical therapy is suggested. Because Conception occurred more
quickly in this technique than ovarian cystectomy in literature (6%
versus 22%). Recurrent pain was minimal in this research. But
broader research will be needed in this field.
150
100
References
50
0
Series1
patients
189
mean age
28
year
5
fig: Endometrioma in
TVS (Dr.Athar
Rasekh)
management method of endometrioma
1000
17
3
10
70
40
3
Dr Rasekh during laparoscopic Endomtrioic
patient procedure in Jahrom Pymanyh Hospital.