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REPRODUCTIVE ENDOCRINOLOGY AND INFERTILITY

Repeat transvaginal ultrasound-guided aspiration of ovarian endometrioma in infertile women with endometriosis Wenjie Zhu, MD; Zhen Tan, MM; Zhihong Fu, MD; Xuemei Li; Xiumin Chen; Yonghong Zhou OBJECTIVE: We sought to investigate the effectiveness of repeated

transvaginal ultrasound-guided aspiration of endometriomas in infertile women with endometriosis. STUDY DESIGN: A retrospective study was performed in our depart-

ment of reproductive health on 129 infertile women who underwent monthly repeated transvaginal aspiration of endometriomas. The recurrence and pregnancy were monitored during a follow-up period of 24 months. RESULTS: Recurrences of cysts were found in 118 (91.5%) patients in

the first postaspirate month and 86 (66.7%) in the second, 60 (46.5%)

in the third, 28 (21.7%) in the fourth, 12 (9.3%) in the fifth, 7 (5.4%) in the sixth, and 36 (27.9%) in the 24th postaspiration month. Mean 3.1 ⫾ 2.8 times of aspirations per patient were performed without any adverse effect. There was a linear regression relationship between the change of times of aspirations and the chance of recurrence of cysts. Overall pregnancy rate of 43.4% (56/129) was obtained. CONCLUSION: The repetitive aspiration of endometriomas is an effec-

tive therapeutic option in patients with endometriosis. Key words: aspiration, endometrioma, pregnancy, recurrence, repeated

Cite this article as: Zhu W, Tan Z, Fu Z, et al. Repeat transvaginal ultrasound-guided aspiration of ovarian endometrioma in infertile women with endometriosis. Am J Obstet Gynecol 2011;204:61.e1-6.

A

lthough endometriosis is a common disease among women of reproductive age, the optimal management approach toward it is still controversial. Surgical and hormonal treatments are 2 traditional methods. However, none of these has absolute advantage or disadvantage over the other in terms of reproductive success. In general, surgery is advocated when a patient is diagnosed with persistent ovarian endometriomas despite hormonal treatment. Laparoscopic cystectomy to remove ovarian endometriomas is

From the Department of Reproductive Health and Department of Gynecology, Shen-Zhen City Maternity and Child Healthcare Hospital, Shen-Zhen, GuangDong Province, Peoples Republic of China. Received Feb. 10, 2010; revised July 6, 2010; accepted Aug. 24, 2010. Reprints: Wenjie Zhu, MD, No. 3012, Fu-Qiang Road, Shen-Zhen City, 518048, Guang-Dong Province, China. zhuwenjie542004@yahoo.com.cn. 0002-9378/$36.00 © 2011 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2010.08.040

Click Supplementary Content under VIDEO the article title in the online Table of Contents

an effective procedure, but presence of pelvic adhesions can make it difficult to visualize anatomic structures, leading to suboptimal resection, cyst recurrence, and surgical complications, such as hemoperitoneum, rectovaginal fistula, anastomotic leakage/fistula, ureteral fistula/uroperitoneum, bowel perforation, pelvic abscess, need for temporary loop ileostomy, postoperative bowel or ureteral anastomotic stenosis, neurogenic bladder dysfunction, constipation, and peripheral sensory disturbance, which may further jeopardize the reproductive status of the women.1 Therefore, ultrasound-guided endometrioma aspiration has been proposed as an alternative therapeutic modality in selected patients for the relief of symptoms2 or patients undergoing infertility treatment to improve reproductive outcome.3 Studies have reported varying rates of recurrence after simple aspiration. Transvaginal, ultrasound-guided ovarian endometrioma aspiration as an effective treatment is still controversial with studies being reported both in favor4 as well as against5 aspiration. In the present study, our aim is to investigate the therapeutic efficacy and reproductive outcome following repeated transvaginal ultrasoundguided endometrioma aspiration in infertile women with endometriosis.

M ATERIALS AND M ETHODS This is a retrospective study involving 129 of 140 patients with pelvic endometriosis undergoing single or repeated transvaginal ultrasound-guided ovarian endometrioma aspiration treatment at our department of reproductive health from January 2000 through July 2007. In all, 7.9% (11/140) of the patients were lost to follow-up (3 during the first year and 8 during the second), and were not included in this study. All these women presented with infertility for at least 2 years and had been seeking pregnancy in varying duration. The mean (⫾SD) age was 32.6 ⫾ 4.3 years and the mean duration of infertility was 4.1 ⫾ 2.2 years. All subjects were diagnosed with ovarian endometriomas by transvaginal ultrasound scan (Aloka-1000, UST-985, 5-MHz transvaginal probe; Aloka Co Ltd, Tokyo, Japan), or by previous laparoscopic surgery or laparotomy treatment for pelvic endometriosis and endometriomas were being seen because of a recurrence. Prior to aspiration, 112 patients had received hormonal treatment: 47 danazol (600-800 mg/d in divided doses for 4-7 months), 39 gonadotropinreleasing hormone agonist (GnRH-a) (triptorelin 3.75 mg/6 weeks for 3-6 months), and 26 Diane-35 (1 tablet/d, 21

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TABLE 1

Characteristics of 129 patients with endometriomas Characteristics

No. of patients (%) or mean ⴞ SD

Age, y

32.6 ⫾ 4.3

..............................................................................................................................................................................................................................................

4.1 ⫾ 2.2

Duration of infertility, y

..............................................................................................................................................................................................................................................

Infertility

.....................................................................................................................................................................................................................................

Primary

88 (68.2)

Secondary

41 (31.8)

..................................................................................................................................................................................................................................... ..............................................................................................................................................................................................................................................

46.4 ⫾ 19.5

CA-125 level, U/mL

..............................................................................................................................................................................................................................................

Preaspirate hormonal treatment

.....................................................................................................................................................................................................................................

GnRH-a

39 (30.2)

Danazol

47 (36.4)

Diane-35

26 (20.2)

..................................................................................................................................................................................................................................... ..................................................................................................................................................................................................................................... ..............................................................................................................................................................................................................................................

Previous surgery for ovarian endometriosis

53 (41.08)

Single cyst

99 (76.7)

.............................................................................................................................................................................................................................................. .....................................................................................................................................................................................................................................

9.3 ⫾ 6.2

Diameter of cysts, cm

..............................................................................................................................................................................................................................................

Multiple cysts

30 (23.3)

.....................................................................................................................................................................................................................................

Diameter of largest cyst, cm

8.2.⫾ 5.0

..............................................................................................................................................................................................................................................

Side of cyst

.....................................................................................................................................................................................................................................

Right

56 (43.4)

Left

46 (35.7)

Bilateral

27 (20.9)

..................................................................................................................................................................................................................................... ..................................................................................................................................................................................................................................... ..............................................................................................................................................................................................................................................

Diane-35; Schering GmbH & Co. Productions KG, Weimar, Germany. GnRH, gonadotropin-releasing hormone agonist. Zhu. Repeated aspiration treatment for endometriomas. Am J Obstet Gynecol 2011.

tablet/mo for 3-9 months; Schering GmbH & Co. Productions KG, Weimar, Germany). A total of 53 patients had undergone surgical treatments, of whom 24 had laparotomy done with ovarian cystectomy and adhesiolysis and had reported again with recurrence of ovarian endometriomas. In all, 29 women had laparoscopic fulguration of endometriotic implants and adhesiolysis to improve fertility, but had failed to conceive on a follow-up of ⬎2 years with recurrence of endometriotic cysts. Aspirations or reaspirations were not done in those who presented genital infection or cardiovascular, respiratory, mental, hepatic, or renal disorders. In addition, patients who opted for in vitro fertilization-embryo transfer during follow-up period after they had received aspiration or reaspiration of cysts (3 of 8 patients who were lost to follow-up during the second year) were not included in this 61.e2

study. All patients’ characteristics are shown in Table 1. Cyst aspiration was done on an outpatient basis. An intramuscular injection of 50-100 mg of pethidine hydrochloride (Shenyang First Pharmaceutical NEPG, Shen-Yang, China) was administered to each woman just before starting the procedure. The procedure proceeded in accordance with that reported by Mittal et al.3 After emptying the bladder, the women were placed in lithotomy position. They were then prepped using an aseptic vulva and vaginal douche. An ultrasound examination was carried out just before the aspiration and the optimal site for puncture was selected. The needle guide was attached to the ultrasound probe after cleaning and covering it with a sterile condom. Under transvaginal ultrasonographic guidance, a 16-gauge, 350-mm long needle

American Journal of Obstetrics & Gynecology JANUARY 2011

www.AJOG.org was used for transvaginal puncture and inserted into the endometriomas and the contents were aspirated. The progress of the needle was observed through the tissues on the ultrasound until the tip was visualized well within the cyst. The needle tip was monitored throughout aspiration. High negative pressure of 200-400 mm Hg during aspiration was controlled and regulated manually according to the thickness of contents (Videos 1-18). To prevent the contents of cysts leaking from the cyst wall, postaspiration normal saline irrigation was avoided. A little normal saline may be used during aspiration only when the contents are too sticky to be aspirated. All contents aspirated from the cysts were subjected to cytopathological examination. Postoperative recurrences of endometriomas were monitored by monthly transvaginal ultrasound scan. Single or multiple cysts of ⱖ30 mm diameter after first aspiration was the indication for reaspiration, which was performed 3-5 days after the menstrual period of the following cycle. Repeated aspirations were done monthly if the recurrent cysts reached the size needed to aspirate. All patients were directed to try to conceive and followed up for 2 years after aspiration. All patients were informed that this was a simple and safe technique, and its clinic efficacy had not been confirmed yet, although some previous studies described this technique in the literature for the same purpose with a good outcome. Subjects all signed an informed consent form. Institutional review board approval was not required for this retrospective study. Statistical analysis was performed using the Fisher’s exact test where appropriate. A linear test for trend (linear regression) was used to analyze a linear regression relationship between the changes of times of aspirations (independent variable) and the chances of recurrences of cysts (dependent variable). A P value ⬍ .05 was considered statistically significant. All statistics were performed using software (SPSS 13.0; SPSS Inc, Chicago, IL).


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TABLE 2

Correlation of initial cyst size with postaspiration recurrence and reaspiration Recurrence and reaspiration, n (%) Cyst size, cm

Aspiration, n (%)

First

Second

Third

Fourth

Fifth

Sixth

3-5

24 (18.6)

21 (16.3)

17 (13.2)

11 (8.5)

2 (1.6)

5-9

53 (41.1)

48 (37.2)

33 (25.6)

20 (15.5)

10 (7.8)

3 (2.3)

1 (0.8)

9-12

43 (33.3)

40 (31)

28 (21.7)

21 (16.3)

9 (7.0)

5 (3.9)

3 (2.3)

⬎12

9 (7.0)

9 (7.0)

8 (6.2)

8 (6.2)

7 (5.4)

4 (3.1)

3 (2.3)

Total

129 (100.0)

118 (91.5)

86 (66.7)

60 (46.5)

28 (21.7)

12 (9.3)

7 (5.4)

................................................................................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................ a ................................................................................................................................................................................................................................................................................................................................................................................

n ⫽ no. of patients aspirated. a

There was linear regression relationship between times of aspirations and recurrences of cysts. Each increase with aspiration would decrease recurrence chances of mean 22 patients in total (y ⫽ 153.714-22.714X, R2 ⫽ 0.971).

Zhu. Repeated aspiration treatment for endometriomas. Am J Obstet Gynecol 2011.

Cytology of aspirates in all patients revealed multiple hemosiderin-laden macrophages, negative for neoplastic cells and compatible with the diagnosis of endometriosis. All 129 patients had ultrasound reexamination following the aspiration every month for a minimum of 6 months. Afterward the interval of ultrasound examination was adjusted for 1-2 months up to 24 months. In all, 48 (37.2%) patients volunteered to receive postoperative medication: 13 received GnRH-a (triptorelin 3.75 mg/6 weeks for 3 months) and 35 received Diane-35 (1 tablet/d, 21 tablets/mo for 3 months; Schering GmbH & Co. Productions KG). Of the 129 women, 118 (91.5%) had recurrences of cysts in the first postaspiration month and reaspirations were performed immediately for them. After that, 86 (66.7%) had recurrence in the second, 60 (46.5%) in the third, 28 (21.7%) in the fourth, 12 (9.3%) in the fifth, and 7 (5.4%) in the sixth postaspiration month and reaspirations were performed right away for them at each corresponding month. Mean 3.1 ⫾ 2.3 times of aspirations per patient were performed. None of the patients had undergone ⬎7 aspirations or reaspirations. The interval between 2 aspirations varied from 26-39 days (mean 33 ⫾ 6 days). Single cyst aspirations were performed in 102 women and 27 patients underwent bilateral cyst aspirations or reaspirations. There were no aspirationrelated adverse events. The surgical procedure lasted for 7-41 minutes. The

contents became thinner and thinner, and the time for each reaspiration was shorter and shorter when repeated aspirations were done. Volume aspirated varied from 26-370 mL. The size of the larger cyst and volume aspirated was correlated. For different groups of 3-5, 5-9, 9-12, and ⬎12 cm in terms of size of cysts, correlation of initial cyst size with postaspiration recurrence and reaspiration is displayed in Table 2. The recurrent rates were decreased gradually fol-

lowing monthly repeated aspirations (Figure). A linear test for trend (linear regression) shows that there was a linear regression relationship between the changes of times of aspirations (independent variable) and the chances of recurrences of cysts (dependent variable). Each increase with aspiration would decrease the recurrent chances of the mean 22 patients in total (y ⫽ 153.71422.714X, R2 ⫽ 0.971), 5 patients in 3-5

FIGURE

Relationship between times of aspirations and recurrence of cysts

Recurrent rate(%)

R ESULTS

100.00 80.00 60.00 40.00 20.00 0.00 1st

2nd

3rd

4th

5th

6th

7th

Aspiration (time) Zhu. Repeated aspiration treatment for endometriomas. Am J Obstet Gynecol 2011.

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TABLE 3

Recurrences and pregnancies in varied patients and months of follow-up, n (%) Months of follow-up Variable

1-3

4-6

No. of recurrences

7-9 9

10-12 7

13-15 5

16-18 8

19-21

22-24

Total

4

3

36 (27.9)

................................................................................................................................................................................................................................................................................................................................................................................ a

Cyst size, cm

.......................................................................................................................................................................................................................................................................................................................................................................

ⱖ9

4

4

1

5

2

1

17 (32.7)

⬍9

5

3

4

3

2

2

19 (24.4)

....................................................................................................................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................................................................................................................................ a

Preaspirate medical treatment

.......................................................................................................................................................................................................................................................................................................................................................................

Yes

7

6

5

6

4

3

31 (27.7)

No

2

1

0

2

0

0

5 (29.4)

....................................................................................................................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................................................................................................................................ a

Postaspirate medical treatment

.......................................................................................................................................................................................................................................................................................................................................................................

Yes

4

2

1

3

1

1

12 (25.0)

No

5

5

4

5

3

2

24 (29.6)

....................................................................................................................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................................................................................................................................ a

Side of cyst

.......................................................................................................................................................................................................................................................................................................................................................................

Left

4

2

2

2

1

1

12 (26.1)

Right

4

3

3

4

2

2

18 (32.1)

....................................................................................................................................................................................................................................................................................................................................................................... .......................................................................................................................................................................................................................................................................................................................................................................

Bilateral

1

2

0

2

1

0

6 (22.2)

8

11

12

10

5

2

56 (43.4)

................................................................................................................................................................................................................................................................................................................................................................................

No. of conceptions

2

6

................................................................................................................................................................................................................................................................................................................................................................................ a

Cyst size, cm

.......................................................................................................................................................................................................................................................................................................................................................................

ⱖ9

1

2

4

4

6

4

2

1

24 (46.2)

⬍9

1

4

4

7

6

6

3

1

32 (41.6)

....................................................................................................................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................................................................................................................................ a

Preaspirate medical treatment

.......................................................................................................................................................................................................................................................................................................................................................................

Yes

2

5

7

9

10

9

4

2

48 (42.9)

No

0

1

1

2

2

1

1

0

8 (47.1)

....................................................................................................................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................................................................................................................................ a

Postaspirate medical treatment

.......................................................................................................................................................................................................................................................................................................................................................................

Yes

0

2

3

4

5

4

2

1

21 (43.8)

No

2

4

5

7

7

6

3

1

35 (43.2)

....................................................................................................................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................................................................................................................................ a

Side of cyst

.......................................................................................................................................................................................................................................................................................................................................................................

Left

1

2

3

4

4

3

1

1

19 (41.3)

Right

1

3

3

5

5

4

3

1

25 (44.6)

Bilateral

0

1

2

2

3

3

1

0

12 (44.4)

....................................................................................................................................................................................................................................................................................................................................................................... ....................................................................................................................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................................................................................................................................

n ⫽ no. of patients. a

No statistically significant differences were found when comparing rates of recurrence and pregnancy.

Zhu. Repeated aspiration treatment for endometriomas. Am J Obstet Gynecol 2011.

cm group (y ⫽ 30.800-5.229X, R2 ⫽ 0.969), 7 patients in 5-9 cm group (y ⫽ 62.429-6.607X, R2 ⫽ 0.964), 7 patients in 9-12 cm group (y ⫽ 51.143-7.464X, R2 ⫽ 0.965), and 1 patient in ⬎12 cm group (y ⫽ 11.000-1.036X, R2 ⫽ 0.862). Postoperative follow-up were completed in all patients up to 24 months. The final recurrences of cysts were found in 27.9% (36/129) patients (16 during the first year and 20 during the 61.e4

second). There were no significant differences in the recurrence rates of cysts between the patients with and without previous surgery or postoperative medication; with left cysts and right cysts; or with larger cysts and smaller cysts. The distribution of recurrences in various patients and months is described in Table 3. Conception was planned following operations. A total of 56 women con-

American Journal of Obstetrics & Gynecology JANUARY 2011

ceived during the follow-up period. Overall pregnancy rate of 43.4% (56/ 129) was obtained. Twelve patients achieved pregnancy by intrauterine insemination, 9 due to abnormalities of the husband’s semen and 3 due to cervical factors. The remaining 44 conceived naturally. In all, 73.2% (41/56) of the pregnancies were obtained in the duration between the 7th and 18th postoperative month. No significant difference was


www.AJOG.org found when the pregnancy rates among above-mentioned various patients were compared (Table 3). To date, 45 healthy babies have been delivered and 7 women are in ongoing pregnancies. Abortion occurred in 3 and 1 patient had ectopic pregnancy.

C OMMENT In the present study, we analyzed the reproductive outcomes of 129 infertile patients who underwent repeated transvaginal ultrasound-guided aspiration of endometrioma. With accumulated pregnancy rate of 43.4% for 2 years of followup, the procedure was considered an effective therapeutic option in patients with endometriomas. Transvaginal aspirations of endometriomas were tried as an alternative therapeutic modality in patients with endometriomas.3,6,7 The reproductive outcome was comparable with conservative surgical management including laparoscopy. However, one problem present in these studies was the higher recurrence rate, which made it difficult for the patients to achieve pregnancy. This was an important factor why this simple and safe therapeutic modality was not extensively spread and applied. In our series of 129 patients, we found that the recurrence rates were reduced by repeated aspirations of cysts. It was 91.5% in the first postaspirate month, and 66.7% in the second. However, it was decreased to 5.4% after 6 consecutive aspirations. If the repeated aspirations were continued, we believed that the recurrence rate would be controlled at a very low level and an optimal therapeutic effect could be achieved. The causes of infertility for patients with endometriosis may be in varied aspects including immunologic, mechanical, and endocrine; however, all of these factors are associated with the ectopic endometrial tissue. If only 1 time of aspiration could remove completely the ectopic endometrial tissue, the recurrence would be avoided. The recurrence rate reduced by repetitive aspirations can be explained by pathophysiology of endometriosis. The cyclic bleeding can occur in ectopic endometrial tissue as does in entopic endo-

Reproductive Endocrinology and Infertility metrium. Finally, the endometrioma forms gradually, and becomes larger and larger. The content becomes stickier due to the absorption of the water part of the content. Importantly, the inflammation that occurred in normal tissues adjacent to cyst made it difficult to define the wall of cyst from the normal tissue. In a report about laparoscopic cystectomy the normal ovarian tissue adjacent to the cyst wall was detected in 71% of patients with endometriosis, whereas normal ovarian tissue was removed from only 5.4% of patients with other benign cysts.8 The residuals of cyst wall and content have a bearing on the recurrence of the cyst. Disappeared after aspiration, the cyst is refilled with much more fluid at subsequent aspirations. This may be explained with the exfoliation/menstruation of residual endometriotic tissues or tissue reaction from mechanical stimulation of aspiration. Additionally, the sticky content and thick cyst wall indicate a long disorder process, which results in a suboptimal aspiration with much more residual of contents and wall. It does not seem likely that aspiration of the cyst contents would aspirate the endometriotic plaque on the wall. The recurrence risk of 28% at 2 years may be indicative of the slow sloughing of endometrial tissues from the cyst wall with rising recurrence rates if followed longer still. However, we believe each aspiration will remove more or less the endometriotic tissues shedding from the wall following the change of menstrual cycle or the effect of previous aspiration. Following repeated aspirations, the endometrial tissues appear to line only a small portion of the cyst wall and result in a low rate of recurrence and slow growing. Without residual postaspirate endometriotic tissues, cyst walls collapse due to scarring making reaccumulation impossible. We consider that the more residual the ectopic endometrial tissue is, the more severe the detriment to reproductive function. Furthermore, relief or loss of mechanical pressure from the endometriomas is beneficial to ovarian blood supply, ovarian reserve, follicle growth, and achievement of pregnancy. Infertility is still an important problem in many patients with endometriosis.

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The estimate has been recently confirmed by long-term follow-up data indicating an overall probability of reoperation of 54-58% after 5-7 years with laparoscopic operation.9,10 This figure was as high as 72% in the 19- to 29-yearold age group. Normal ovarian tissue adjacent to the cyst wall was detected in 58.7% of patients who underwent a laparoscopic cystectomy, leading to loss of primordial, primary, and secondary follicles.8 A short communication11 described the delayed onset of premature ovarian failure in some young patients between 5-24 months after operative laparoscopy for ovarian endometriosis, which is of particular concern to young patients who are referred for video laparoscopy as a treatment for ovarian endometriosis.12 The 43% pregnancy rate makes this approach viable since the laparoscopic therapies are not without negative consequences. A recent study showed that 12- and 24-month cumulative pregnancy rates were 13% and 22% after repetitive surgery for recurrent endometriosis in infertile women compared with 25% and 30% in first-line procedure.13 Compared with traditional operative approaches, laparoscopy or laparotomy, transvaginal repeated endometriomas aspiration is a simple, safe, inexpensive, and easily repeatable therapeutic modality with comparable reproductive success. In our patients, normal saline was not used to irrigate the cyst following the aspiration. Although the wall or membrane adhered to the normal tissue tightly, it was thin and weak. In the previous laparotomy of endometriomas, we found it very difficult to separate endometrioma from normal tissues, but the cyst was easy to break even if the surgeon did it carefully. It was possible that the irrigation with normal saline could cause leakage of the content from the hole aspirated or rupture caused by irrigation itself, which may lead to spread and implantation of ectopic endometrial tissues. We did not use antibiotic prophylaxis. Interestingly, none of our patients had infection due to the aspiration procedure, just as no infection occurred after oocyte retrieval during in vitro fertilization-embryo transfer program

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without any antibiotic therapy in our center. Some other studies reported that sclerotherapy with 95% ethanol2 or methotrexate14 following the aspiration of cysts relieved the recurrence of endometriomas. The mechanism of treatments was to try to destroy the residual wall of cyst. However, recurrence still was not avoided.2 It is dangerous in the case of inadvertent injection of alcohol into the peritoneal cavity. In the present study, we found that preaspirate or postaspirate medical treatment did not offer any advantages to our patients with regard to facilitating operation or postaspirate recurrence. Muzii et al15 also showed that preoperative medical GnRH-a treatment for ovarian endometriosis did not support any benefit for endometriosis-associated infertility. Some studies demonstrated that previous preoperative medical treatment was a risk factor for recurrence after cystectomy of ovarian endometriomas.16,17 A recent study argues that preoperative medical treatment may actually be detrimental for patients with ovarian endometriosis.14 Although the operative pattern of laparoscopic cystectomy or laparotomy differs from that of aspiration of cyst, the present study showed that the rates of recurrence and pregnancy following repetitive aspiration of cysts were not improved by preaspirate or postaspirate medical treatment. How-

61.e6

ever, a randomized controlled study on preaspirate or postaspirate medical treatment is essential to determine the best therapeutic option in terms of both recurrence rate and pregnancy rate. In summary, the repetitive aspiration of endometriomas is an effective therapeutic option for patients with endometriosis. f REFERENCES 1. Fleisch MC, Xafis D, De Bruyne F, Hucke J, Bender HG, Dall P. Radical resection of invasive endometriosis with bowel or bladder involvement: long-term results. Eur J Obstet Gynecol Reprod Biol 2005;123:224-9. 2. Hsieh CL, Shiau CS, Lo LM, Hsieh TT, Chang MY. Effectiveness of ultrasound-guided aspiration and sclerotherapy with 95% ethanol for treatment of recurrent ovarian endometriomas. Fertil Steril 2009;91:2709-13. 3. Mittal S, Kumar S, Kumar A, Verma A. Ultrasound guided aspiration of endometrioma–a new therapeutic modality to improved reproductive outcome. Int J Gynecol Obstet 1999; 65:17-23. 4. Giorlandino C, Taramanni C, Muzii L, Santillo E, Nanni C, Vizzone A. Ultrasound guided aspiration of ovarian endometriotic cysts. Int J Gynaecol Obstet 1993;43:41-4. 5. Zanetta G, Lissoni A, Dalla Valle C, Trio D, Pittelli M, Rangoni G. Ultrasound-guided aspiration of endometriomas: possible applications and limitations. Fertil Steril 1995;64:709-13. 6. Martin DC. Pain and infertility–a rationale for different treatment approaches. Br J Obstet Gynecol 1995;102:2-3. 7. Dicker D, Goldman JA, Feldberg D, Ashkenazi J, Levy T. Transvaginal ultrasonic needle guided aspiration of endometriotic cysts before ovulation induction for in vitro fertilization. J In Vitro Fert Embryo Transf 1991;8:286-9.

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www.AJOG.org 8. Matsuzaki S, Houlle C, Darcha C, Puoly JL, Mage G, Canis M. Analysis of risk factors for the removal of normal ovarian tissue during laparoscopic cystectomy for ovarian endometriosis. Hum Reprod 2009;24:1402-6. 9. Cheong Y, Tay P, Luk F, Gan HC, Li TC, Cooke L. Laparoscopic surgery for endometriosis: how often do we need to re-operate? J Obstet Gynecol 2008;28:82-5. 10. Shakiba K, Bena JF, McGill KM, Minger J, Falcone T. Surgical treatment of endometriosis: a 7-years follow-up on the requirement for further surgery. Obstet Gynecol 2008;111: 1285-92. 11. Di Prospero FD, Micucci G. Is operative laparoscopy safe in ovarian endometriosis? Reprod Biomed Online 2009;18:167. 12. Di Prospero F, Micucci G. Late onset premature ovarian failure (POF) after laparoscopic excision of ovarian endometriosis. Gynecol Endocrinol 2008;24(Suppl):256-7. 13. Vercellini P, Somigliana E, Daguati R, Barbara G, Abbiati A, Fedele L. The second time around: reproductive performance after repetitive versus primary surgery for endometriosis. Fertil Steril 2009;92:1253-5. 14. Mesogitis S, Antsaklis A, Daskalakis G, Papantoniou N, Michalas S. Combined ultrasonographically guided drainage and methotrexate administration for treatment of endometriotic cysts. Lancet 2000;355:1160. 15. Muzii L, Marana R, Caruana P, Mancuso S. The impact of preoperative gonadotropin-releasing hormone agonist treatment on laparoscopic excision of ovarian endometriotic cysts. Fertil Steril 1996;65:1235-7. 16. Koga K, Takemura Y, Osuga Y, et al. Recurrence of ovarian endometrioma after laparoscopic excision. Hum Reprod 2006;21:2171-4. 17. Liu X, Yuan L, Shen F, Zhu Z, Jiang H, Guo SW. Patterns of and risk factors for recurrence in women with ovarian endometriomas. Obstet Gynecol 2007;109:1411-20.


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