Questions that need to be addressed when treating endometriomas on the ovary

1.     How old is the woman

2.     Has there been previous surgery for ovarian endometriosis

3.     What symptoms is the cyst causing

4.     Is fertility an immediate issue

5.     If fertility is not an immediate issue what will be done to prevent recurrence

Endometriomas are ovarian cysts caused by endometriosis.

Most times they are as a result of adhesions between the pelvic sidewall and the ovary caused by endometriosis.

Endometriosis is characterized by symptoms of pain during periods (sometimes also when not having periods), and may also be implicated in infertility problems.

Most endometriomas are diagnosed on the basis of symptoms and results of an ultrasound scan

Because of what we now know about the effect of endometriomas on the ovary and its function, and the effects of  surgery on future ovarian function, it is important the doctors treat each patient diagnosed individually taking into consideration:

1.     The age of the patient

a.     The age of the woman is important as over the age of 40 there may be increased relative risk of developing cancer of the ovary as a result of endometriosis

2.     The life stage of the patient

a.     Whether fertility is an immediate issue

b.     Whether surgery has taken place already on the ovary

It is now thought that leaving the endometriomas on the ovary has a detrimental effect on the ovary. It can cause

1.     Oxidative stress

2.     Production of toxins that may harm the ovary

3.     Reduction of the number of follicles

4.     Increased fibrosis within the ovary

However treatment of the ovary may lead to

1.     reduced AMH levels

a.     AMH is a maker of ovarian reserve

2.     Reduced response to ovarian stimulation if IVF is required

3.     Premature ovarian failure in 2.4% of women after repeat operation depending on age

For these reasons it is important to balance treatment of the endometriomas with considerations to prevent the endometriomas from coming back. (The risk of it coming back is in the region of about 12% after formal removal of the endometrioma. If it is only drained the risk of recurrence is about 100%). 

Adenomyosis can be diffuse or focal. the ultimate management of adenomyosis is hysterectomy however many young women who have not completed their families also suffer from adenomyosis. After investigation it may be possible for this to be excised laparoscopically. It is important that the diagnosis be made early as the smaller the lesion the greater the likelihood of laparoscopic surgery being successful. for larger lesions open surgery may be an alternative however there is the associated risk with traditional open surgery

Unfortunately fibroids regrow in a good number of women who have surgery for uterine fibroids.

This in itself is not a problem for women who have managed to achieve their reproductive desires and have finished child bearing.

Women who either have not become pregnant or have recurrence of their symptoms whose fibroids have regrown need to consider their choices and what the realistic chances of reaching their objectives are.

Their choices of course will depend on:

The number of fibroids that have regrown

The location of the fibroids that have regrown

The size of the fibroids that have regrown.

They also need to consider the age at which they had their original myomectomy and the age they are when they consider having a repeat procedure.

Factors that will also affect choice will be

How the original myomectomy was performed whether laparoscopically or by traditional open surgery or by Hysteroscopy.

Problems with a repeat myomectomy include

Increased risk of bleeding during the operation

Increased chance of bowel injury during the operation

Increased chance of bladder injury during the operation

Increased chance of hysterectomy during, or after the operation.

Fertility after a second myomectomy

After the first procedure the chances of pregnancy a high, particularly for women who had a fibroid in the uterine cavity. 75% of women who will get pregnant usually do so within the first year after the procedure.

Fertility is not that good after a second abdominal myomectomy with pregnancy rates being as low as 15%.

What are adhesions?

Adhesions occur as a part of the bodies healing process. When the body is injured either surgically, by infection or otherwise mechanisms are activated to promote healing. Sometimes this is not perfect and results in scar tissue, which is responsible for adhesions. On occasion when two different structures are near or touching each other, and both are involved in the healing process they become stuck together either completely or become joined together by filmy strands that were involved in the healing process.

Adhesions can result from any surgery; some operations produce more adhesions than others particularly those that result in a lot of bleeding during the procedure.

Why are adhesions important?

For most people adhesions will produce no symptoms however, adhesions can be responsible for

• Pain
  
• Intestinal (bowel) obstruction
  
• Infertility if they involve the pelvis particularly the fallopian tubes in women
  

What can be done to reduce adhesions?

Being fit and as healthy as possible before an operation will reduce the risk of adhesions.

Surgeons can also play a part in adhesion reduction by

•  Using good surgical technique
  

•  Reducing the exposure of tissue to the atmosphere (intermittent perfusion of tissue or covering the tissue with          moist swabs)
  

• Reduction in the amount of bleeding
  

• Reducing the risk of infection
  

• The use of laparoscopic surgery for some procedures reduces the risk of adhesions by half.
  

• The use of anti-adhesive agents at the time of surgery
  

These agents are becoming increasingly important particularly in patients undergoing surgery for fibroids for fertility reasons

What can be done about adhesions?

For most people with no symptoms no intervention is required. The only reason for intervention would be

•  Symptoms of intestinal obstruction
  

• Improvement of fertility in selected patients
  

• Reduction of pain symptoms
  

 Unfortunately pain symptoms will not improve with surgery in all patients
In some patients the symptoms can be more severe. This is because sometimes the process that was involved in the production of adhesions works twice as hard to prevent adhesions the second time resulting in denser and thicker scar tissue.
For this reason there are advantage of managing symptoms of pain with conservative measures rather than surgery

Laparoscopic surgery and adhesions

1.     Laparoscopic surgery can reduce the risk of adhesion formation. This is because tissues are touched less often and tissues tend to be “washed” periodically during surgery

Laparoscopic surgery in patients with adhesions

1.     Advantages

•  Laparoscopic surgery can have advantages in patients who have had previous surgery and are thought to have adhesions
  

•  Better visualization of tissues and structures
  

2.     Disadvantages

• Laparoscopic surgery can potentially be dangerous in women who have adhesions as there can be an increase in the risk of bowel injury in such patients
  

• Surgeons usually insert the surgical ports away from the site of surgery to prevent bowel damage. 
  

• If the adhesions are too dense then open surgery may be necessary
  

The fallopian tubes are responsible for the transport of the male sperm and the female egg, or the embryo from the ovary to the uterus. It is therefore an essential component of a woman’s ability to get pregnant spontaneously (without any medical help).

Occasionally the fallopian tubes can become blocked. The most common reason for tubal blockage is pelvic infection (pelvic inflammatory disease), which is most commonly acquired as a sexually transmitted infection. The commonest cause is chlamydia infection.

Blocked fallopian tubes are found in 10-15% of infertile women

There are other possible causes of tubal blockage

·      Endometriosis: where the tubes are blocked due to adhesions

·      Mechanical blockage: sometimes due to the presence of fibroids pressing on the tubes

·      Adhesions from previous surgery

Presentation:

The majority of women have no symptoms but some will present with

Pelvic pain due to enlargement of the fallopian tube. Alternatively the swollen fallopian tube may be found during investigation for infertility

Investigations:

Often your doctor will ask you to have a hysteroalpingogram (this is an x-ray test used to visualize dye put through the fallopian tubes), or a laparoscopy.

Management

The aims of management are to

1.    Restore the anatomy of the fallopian tube

2.    Restore fertility

These objectives are met using operative laparoscopy

It is relatively easy to open up the tube and let the fluid out; fertility on the other hand depends on the degree of damage to the end of the fallopian tube.

The degree of damage is usually graded I-IV with one being the least and IV the worst.

Fertility rates after repair range from 19-48%

In some cases depending on the degree of damage doctors may advise that the fallopian tubes be clipped or removed to improve chances of success with IVF

Fibroids are the most common tumor of the womb in women of reproductive age.

In some women they can be responsible for either menstrual period problems or problems with fertility.

Fibroids cause infertility mainly by distortion of the cavity of the womb and sometimes by mechanical obstruction of the fallopian tubes.

When fibroids cause problems during reproductive life some women may be advised to have their fibroids removed.

Fibroid removal is usually achieved by either

1.     Traditional open myomectomy

2.     Hysteroscopic myomectomy

3.     Laparoscopic myomectomy.

Adhesions “scar tissue” are a consequence of healing, where tissues that are close to each other during the healing process get stuck together as a consequence of the healing process.

Whatever method is used to remove the fibroids adhesion formation may be a consequence of surgery.

The adhesions themselves can be significant complications in women who are seeking to improve fertility.

The adhesions become significant if

1.     They form within the cavity of the womb (intrauterine adhesions) or

2.     If they form on the outside of the womb, distorting the relationship between the fallopian tubes, the womb and the ovaries. This in itself can lead to infertility

After laparoscopic or open myomectomy adhesions can form inside the cavity of the womb (intra-uterine adhesions) if the cavity of the womb is breached during surgery. This on occasion is unavoidable. Up to 30% of women in whom the cavity of the womb is breached during myomectomy will develop intrauterine adhesions.

After hysteroscopic surgery for fibroids between 10-30% of patients will develop intrauterine adhesions.

This risk of developing adhesions increases with the size of the fibroids and the number of fibroids removed particularly if the fibroids are on opposite (apposing) sides of the inside of the womb. One scientific study showed that after one fibroid resection 31% of women developed adhesions and this rose to 45% when 2 fibroids were removed.

Surgeons use various methods to try to prevent adhesions during hysteroscopic surgery but none of these methods carry a guarantee of avoiding adhesion formation.

For women requiring fertility the best method of managing adhesion formation is early identification. Thus after surgery your doctor may advise a check up hysteroscopy to diagnose adhesions and to possibly divide them if they have formed. The same advice would go to women who have had laparoscopic or open surgery for their fibroids in whom the uterine cavity has been breached.

Adhesions after uterine artery embolization

Uterine artery embolization is another conservative method used to treat symptomatic uterine fibroids.

Though there are reports of successful pregnancies after uterine artery embolization it is not the treatment of choice for women who want to retain fertility.

However under certain circumstances it may be offered. In women who need to have uterine artery embolization for the treatment of their fibroids up to 14% will develop intrauterine adhesions.

What are fibroids?

The female uterus is made up of numerous muscle fibres, which are collectively lined internally by fleshy cells (endometrium).

Fibroids are benign growths that originate from the muscle of the womb. In fact each muscle fibre has the potential to grow into a fibroid.

Fibroids are the commonest growth affecting the female genital tract.

They are hormone dependent tumors and tend to grow because of oestrogen stimulation.

Who do they affect?

Depending on the age and race of the population studied they can be seen in up to 50% of the female population. In the majority of women with fibroids there are no symptoms.

They are more common in Afro-Caribbean than in Caucasian women. They tend to present earlier in Afro-Caribbean women and tend to present more commonly as problems with fertility in this group. Caucasian women with fibroids are more likely to have children and complain of heavy menstrual bleeding.

Fibroids tend to run in families

They are commoner in heavier women

They are less common in women who smoke

Why they may be important

The majority of women with fibroids have no symptoms, but when symptoms occur they can be responsible for

1.     Heavy menstrual periods

a.     Leading to anaemia

2.     Infertility

3.     Pressure symptoms

a.     Pressure on bladder causing urinary symptoms

b.     Pressure on bowel causing obstruction and constipation

The symptoms they cause depend on the location of the fibroids

Those within the cavity of the uterus or distorting the cavity are more likely to be responsible for symptoms of heavy bleeding and infertility.

Considerations for treatment

The approach to treating fibroids in women who have symptoms depends on

1.     The size of the fibroid

2.     The location of the fibroid

3.     The number of fibroids

4.     The symptoms that the fibroids are causing

5.     Fertility issues

For women with small fibroids and only heavy periods they may be advised to use medication to ease their symptoms.

For women with significant fibroids, or problems with fertility are usually advised to have surgery.

Hysterectomy is NOT the treatment of choice. It should only be considered in women who have completed their families. Some women who have completed their families may not be comfortable with a hysterectomy. In these women alternative treatments should be considered.

Unfortunately because of the pressures of modern living and socio-economic change, women leave childbirth to a later age. Though in general this makes for better economic status it can have far bearing implications for child bearing.

Apart from the fact that the ovary has a finite number of follicles and as a consequence the older we get the more unlikely it is we are able to achieve pregnancy naturally, there is also an increase in the likely hood that common female genital disorders become more common and more problematic for example fibroids and endometriosis and other contributory environmental factors.

The reproductive capacity every given month is in the region of 20-30%.

If this is the case then this would equate to a 4% infertility rate in women in their 20s compared to 10-20% at age 35.

Increasingly women have to rely on assisted conception techniques in order to get pregnant, but again success rates are age related, in the absence of any overt pathology the younger you are when you attempt IVF the more likely it is to be successful.

Figures given by the human fertilization and embryology authority in the UK in 2007 put the live birth rate at 32% for women under the age of 35 years, 12% between the ages of 40-42years and 3% between 43-44years.

The number of attempts can improve these figures, but again the age related success is demonstrated by the fact that after 6 attempts the success rates for women under the age of 35 is quoted at between 65-86% falling to 23-42% after the age of 40.

Some women opt to freeze their eggs, unfortunately this is not an exact science and women may be better off freezing embryos with a higher success rates of pregnancy. This however may have legal implications if they and their partners are no longer together. In a landmark case, the stored frozen embryos were destroyed.

An investigation used to assess ovarian reserve is the AMH test (anti-mullerian hormone test). This can also be used to predict the potential success rates for women undergoing IVF.

For certain women if this is very low they may be advised to have IVF.

Other issues that women need to consider are the potential implications of having children for the first time after the age of 40, this in itself constitutes a risk, as well as the risk of multiple pregnancies, the increased risk of chromosomal abnormalities, and the older we get the more likely it is we will suffer from medical conditions they may impact the pregnancy. The older we get the heavier we become and obesity in itself may have further impact on the pregnancy. This together with diabetes and hypertension can lead to heart disease.

Increasing maternal age also increases the risk of pregnancy loss, rising from 20% at the age of 35 to up to in excess of 50% over the age of 54. This includes miscarriages and the risk of stillbirth.

The older mum also has an increased risk of being induced, instrumental delivery and caesarean section.

These factors thus need to be tied in to the management of women with gynaecological disorders to they can make the right informed decisions once they have been diagnosed.

Endometriosis affects 20-40% of women with infertility against a background risk of 5-10% of women in the general population. Thus endometriosis can be responsible in some cases for failure to conceive.

It is thought that endometriosis can cause infertility by

·      Making sexual intercourse painful thus women avoid having intercourse (dyspareunia)

·      Altering the pelvic anatomy making it difficult for the sperm and the egg to meet (interfering with fertilization)

·      Interfere with the development of the embryo (after the sperm and egg have met)

·      Interfering with implantation. Interfering with the process by which the embryo embeds itself in the womb

Endometriosis is staged from stage I- 4, and though the actual stage does not determine the ability to get pregnant or symptoms that women have, it is used by doctors and carers to give a possible prognosis and outcome of treatment.

Stage I is minimal disease whilst stage 4 is severe disease

For women who want to get pregnant with endometriosis

It is first important that the male partner have a sperm test to ensure that the semen is of acceptable standard to achieve pregnancy.

 A pelvic ultrasound scan is usually performed as this will help find out whether there are any cysts associated with endometriosis and on occasion can determine the severity of the disease.

If doctors feel that the disease is severe they will ask for other tests.

For women with mild pain symptoms treatment with painkillers may be all that is required and doctors will advise them to try and get pregnant naturally.

Other forms of medical management with hormones are not compatible with fertility.

For women who have more pain a laparoscopy is usually required.

The aim of the laparoscopy would be

1.     To diagnose the disease

2.     To stage the disease

3.     To debulk the disease

a.     To remove all visible disease

4.     Restore anatomy

5.     Test tubal patency

With superficial/minimal endometriosis medical studies have shown that removing the disease improves pregnancy rates in women with endometriosis. One particular study showed a 2 fold increase in fertility rates, however when the study was pooled with other existing data the effect was not that great, the number needed to treat to improve fertility for one person was about 8.

The treatment effect on women with more severe endometriosis is not that clear, however treatment has been shown to improve pain symptoms and thus increase the frequency of intercourse in women who suffered from difficulty with intercourse, thus potentially improving fertility.

In women with ovarian endometriosis (endometriomas) the general advice is to get them treated. This is usually done by laparoscopy. Some medical studies show that removing these cysts can improve pregnancy rates by up to 50%. It also improve painful sex in women who suffer from dyspareunia and painful periods

Removal of the cyst is usually advised as opposed to just drainage of the cyst as this reduces the risk of recurrence.

The recurrence risk is nearly 100% if the cysts are only drained as opposed to removed where the recurrence risk is less than 10%

A more complete assessment is required for women in whom the cysts recur as repeated operations for endometriomas may reduce ovarian reserve and adversely affect pregnancy rates

In relation to IVF there is still great medical debate, but most would suggest that endometriomas larger than 4cm should be treated prior to IVF.

For most women it is best that they be seen to endometriosis experts in endometriosis centers as this optimizes treatment and reduces the risk of recurrence. 

Ovarian cysts are very common. The majority of ovarian cysts are benign (not cancerous). Some cysts given time will disappear by them selves, others will need surgery.





Reasons for surgery would be

1.     Pain that does not improve with simple pain killers

                     a.     This may be a sign of either

                               i.     Bleeding into the cyst

                               ii.     Rupture of the cyst

                              iii.     Torsion of the cyst

2.     A cyst of 5cm or more that is not resolving or increasing in size

3.     If the clinicians are unsure of the nature of the cyst

When surgery is required even for very large ovarian cysts, laparoscopic surgery should be the modality of choice, and most surgery for ovarian cysts are performed as day cases.

The advantage of laparoscopic surgery for ovarian cysts are the fact that

1.     It is less pain full, and less pain killers are required

2.     Hospital stay is less

3.     Recovery and resumption of normal activity is quicker

4.     Blood loss during the procedure is less

5.     Better cosmetic appearance of the scars

The procedure is carried out through an incision in the “belly button” and 2 or 3 small 5mm incisions are often used to insert the fine instruments used for the procedure

Most often women only need to take a few days to a week off work.

It is very rare particularly if the cysts are benign for traditional open surgery to be necessary. I would always advise women to seek a second opinion if they encounter surgeons whose primary method of treatment of ovarian cysts is Laparotomy.