FOGSI FOCUS Endometriosis: Current Trends Kuldeep Jain, Sudha Prasad, Nandita Palshetkar, T Ramani Devi, Fessy Louis T
INDEX
Page numbers followed by b refer to box, f refer to figure, fc refer to flowchart, and t refer to table.
A
Abscess 63
Adenomyoma
large 27f
removal of 27
Adenomyomectomy, laparoscopic 27f
Adenomyosis 17, 24, 26, 27, 37, 74
effect of 25
focal 25f, 27
large focal 25f
Adhesiolysis 44
Adhesion prevention 45
Alcohol consumption 63
American College of Obstetricians and Gynecologists 9fc
American Reproductive Society 13
American Society for Reproductive Medicine 13, 30
classification of Müllerian anomalies 30
Anastrozole 68
Androgens 63
Angiogenesis inhibitors 68
Antiangiogenesis factors 21
Anti-inflammatory agents 68
Anti-Müllerian hormone 58
serum 38
Antioxidants 68
Antiretroviral therapy 17
Antral follicle count 38
Anxiety 6
Aromatase 3
inhibitors 20, 68
Assisted reproductive technology 15, 24, 37, 53, 70, 73
Autoimmune theory 49
B
Biochemical tests 13
Biomolecular theory 2
Bladder 46, 50, 51
endometriosis of 46f, 49, 52, 53
Blood, collection of 25f
Bone mineral density 9
Bowel
disease 7
endometriosis 42, 46
preparations 51
wall infiltration, depth of 51
C
Cabergoline quinagolide 68
Cancer antigen 7
Carbon dioxide 75
Carcinoma 63
Cells
contractile nonmuscle 49
endometrial 49
Cervical
agenesis 30
anomaly 29
aplasia 29
unilateral 29
dysgenesis 30
Cervix
distension of 31
double normal 29
normal 29
Cesarean section 62, 63
Cetrorelix acetate 68
Coelomic metaplasia 1
Meyer and Ivanoff theory of 2
theory 48, 62
Coital function 66
Conservative uterine, role of 27
Constipation 7
Contraceptives pill
combined
hormonal 18
oral 8, 18, 63, 69
oral 6, 19, 26, 39
Controlled ovarian hyperstimulation 75
Corpus
luteal cyst 14
luteum 67
Cyclooxygenase 68
Cyst 63
complex 14, 14f
enucleation 44f
hemorrhagic 14, 67
management, endometrial 10
myometrial 25f
ovarian 15
Cystadenoma 67
Cystectomy 75
endometriotic 44, 45fc
ovarian 38, 75
Cystitis, recurrent 51
Cytochrome P450 3
D
D-amino acid 69
Danazol 20, 26, 68
Deep infiltrating endometriosis 42f, 43, 43f, 48, 50, 53, 54, 69
classification of 53, 54
intestinal 49, 53
retroperitoneal 50f
Depomedroxyprogesterone acetate 9, 68
Depression 6
Dermoid 67
cyst 67
Diarrhea 7, 49
Dienogest 9, 67, 68t
Diethylstilbestrol 30
Direct implantation theory 2
Dopamine receptor 2 agonists 21
Doppler ultrasound 67
Dr David experience 35fc
Drosophila, Ortholog of 4
Dyschezia 49-51
Dysfunction, endometrial 66
Dysmenorrhea 26, 42, 49-51
severe 43, 51
Dyspareunia 6, 42, 49-51, 66
deep 43, 51
E
Elagolix 68
Embryo freezing 59, 60
Embryonic cell rest 1
Endogenous anti-angiogenic activity 21
Endometrioma 9, 11, 14f, 15f, 32, 33, 44, 48, 58, 60, 67, 70, 76
ablation 75
aspiration 75
atypical features of 67, 67t
bilateral 44, 58, 70
externa 62
left-sided 1f, 10
multiple 14f
right ovarian 33f
typical USG features of 67, 67t
Endometriosis 1, 2f, 6, 7, 8f, 13, 17, 18, 21, 29-32, 35, 37-40, 42, 46, 48, 49, 52, 58-60, 62, 66, 67, 70, 73, 74, 77
abdominal wall 62
adolescent 6, 9fc
associated infertility 14, 15
bilateral ovarian 49
challenges in 37
clinical features of 66b
course of 7
cutaneous 62
deep 40, 48, 51
invasive 48
development of 48
diagnosis of 1, 11, 66
endopelvic 62
etiopathogenesis of 1
excise deep 44
extraovarian 67
histological diagnosis of 63
ideal protocol for 38
impact of 58
in vitro fertilization outcomes in 59
infiltrative 14
isolated deep 48
lesions 49
main sites for 42
majority of 14
mechanical cause of 31
medical management of 17
medications used in 18b
mild 2f, 44
mild-to-moderate 73
minimal 44
moderate 44
natural course of 7
pathogenesis of 1, 2
pathophysiology of 18b
prevalence of 6, 48
rectosigmoid 48
rectovaginal 42, 67
recurrence 40
retrocervical 42, 46
retroperitoneal 48
severe 44
stage of 38
suppression of 38
symptoms of 6, 63
theories of 2
treatment of 12, 19
types of 48
ureteric 49, 53
Endometriotic
cells, lymphovascular dissemination of 3f
cyst 73
differential diagnosis of 67, 67t
drainage of 10f
implants 17
ablation of 43
lesions 21, 50
Endometrium, germinal epithelia of 48
Enigmatic disease 42
Environment theory 3
Episiotomy 62
Equine estrogens, conjugated 11
Estradiol 69
Estrogen 18
dependent disease, benign 48
formation, inhibition of 68
Estrogenic receptor isoforms 4
Etanercept 68
Etonogestrel implant 20
European Society of Gastrointestinal Endoscopy 29
European Society of Human Reproduction and Embryology 29, 70
F
Fallopian tubes 62
Fertility
preservation 59
cost-benefit analysis of 60
options of 59
technology 58
preserving surgery 27, 59
prevention 58
sparing
surgery 27
treatment 24
Fertilization 3
Fine-needle aspiration cytology 63
Follicle-stimulating hormone 19, 58, 69
Food and Drug Administration 68t, 69
G
Galactose-1-phosphate uridyltransferase 30
Gastrointestinal symptoms 6, 51
Genes
angiogenic 21
anti-inflammatory 21
Genetic theory 2
Genital tract anomalies, female 29
Gestrinone 68
Glands 48
endometrial 1, 49, 63
Gonadotropin-releasing hormone 9, 18, 26, 67, 68
agonist 8, 19, 38, 39, 67, 69t, 73
therapy 26
analogs 63
antagonists 19, 68
Goserelin 68
acetate 69
Granule 63
Granulosa cells, ovarian 68
Ground glass homogeneous echoes 14f
H
Halban's theory 2
Heavy menstrual flow 63
Hematocolpometra 31
Hematocolpos 31
Hematoma 63
Hematometra 33, 33f
laparoscopic view of 33f
ultrasonography of 33f
Hemiuterus 29
Hemorrhage 14, 15
Hemosiderin-Laden macrophages 1
Herlyn-Werner-Wunderlich syndrome 32, 32f
magnetic resonance imaging of 33f
Hilus sign 67
Hormone
luteinizing 19, 69
therapy 69
combination 9
Hydronephrosis 51, 52
Hydrosalpinx 74
development of 74
Hyperechogenic wall 67
Hypoplasia 29
Hypothalamic-pituitary-ovarian axis 67
Hysterectomy 62
early 63
Hysterolaparoscopy, combined 32
I
Iliac spine, anterior superior 42
Imperforate hymen 29
Implantation
failure 4
impaired 38
In vitro fertilization 37, 67, 73, 76
cycle 59
outcome 59, 74
Incision hernia 63
Infertility 25, 37, 50, 66, 77
Infliximab 68
International Ovarian Tumor Analysis 14
Intestine 50
Intracytoplasmic sperm injection 39, 67, 74
Intrauterine insemination 15, 40, 67
Ipsilateral renal agenesis 32
syndrome 30
Isoflavones 68
K
Kissing ovaries, bilateral 42f
L
Labor, spontaneous onset of 63
L-amino acid, substitution of 69
Laparoscopy 1f, 31, 37, 42, 73
advantages of 9
diagnostic 7
Laparotomy 62
Lesions, hourglass-shaped 50
Letrozole 39, 68
Leuprolide 68
acetate 69
Levonorgestrel intrauterine
device 68
system 8, 19
Lipoma 63
Low ovarian reserve 38
Lower urinary tract symptoms 51
Lymphatic spread, Halban's theory of 2
Lymphoma 63
M
Macrophages 66
Magnetic resonance imaging 31, 37, 50, 52, 67
Malignancy, risk of 64
Mass
abdominal 31
oval 67
Mayer-Rokitansky-Küster-Hauser syndrome 32, 34
Medroxyprogesterone 19
Melatonin 68
Menses, irregular 6
Menstrual bleeding 51
Mesothelial cells 2
Metalloproteinase 3
Meyer and Ivanoff theory 2
Mifepristone 68
Migraine 6
Müllerian agenesis 32
Müllerian anomalies 6, 7, 29-31, 33, 35
classification of 29t
higher incidence of 30
incidence of 34
nonobstructive 31
obstructive 30
prevalence of 30
range of 29
Müllerian defects 30
Müllerian duct 29
anomalies 29
Müllerian malformations 31
Müllerian remnant 2
theory 3
Müllerian structures, abnormal 31
Musculoskeletal disorders 7
Myofibroblasts 49
Myometrium, adjacent 24
N
Nafarelin 68
acetate 69
Nausea 7
Nerves
retroperitoneal 53
sparing surgery, nerve dissection for 45f
Neuroma 63
Nodules
endometriotic 44
excised rectovaginal 43f
Nonsteroidal anti-inflammatory drugs 7-9, 18, 67, 68
Norethindrone acetate 9, 11, 68, 69
O
Obstructed hemivagina, ipsilateral renal agenesis syndrome 30, 32
Oocyte
freezing 59, 60, 67
retrieval 59, 74
risk of 60
Oral lichen planus 68
Ovarian
cortex 70
freezing 60
endometrioma 10, 10f, 70, 74, 77
asymptomatic 74
differential diagnosis of 67, 67t
management of 73
hyperstimulation syndrome 39
inflammation, mechanism of 74
reserve 38, 58
stimulation 40, 59
Ovary 62
endometrioma of 10, 42, 44, 44f
germinal epithelia of 48
Ovulation suppressing agents 68
Ovulatory dysfunction 66
Ovum pick up 66
P
Pain 45
abdominal 7
killers 6
rectal 49
severe
chronic 51
hypogastric 51
Papillae, absence of 67
Papillary projections 67
Parenchyma, ovarian 67
Peculiar atypical red vascular lesions 8f
Pelvic
adhesions 44
endometriosis 62
mass 6
organs 13
pain 18, 32, 37, 42
chronic 6, 42, 43, 50
Pelvis
final appearance of 44f
MRI of 51
Pentoxifylline 21, 68
Peptidoglycan 68
Peripheral estrogen levels 40
Peritoneal endometriosis 42, 48
fulguration of 44f
Peritoneal windows 8f
Peritoneum 62
germinal epithelia of 48
Peritubal adhesions 66
Periureteral vessels 53
Phagocytosis 66
Phytoestrogens 68
Polycystic ovaries 30
Poor oocyte quality 38
Posterior wall fornix lesions 50, 50f
Pouch of Douglas 2, 13, 44, 49-52, 62
Pregnancy loss, recurrent 30
Progesterone 18, 69
containing contraceptives 19
receptor antagonists 68
Progestins 9, 68
Progestogens 63
Progressive estrogen-dependent disease 48
Prostaglandins 7
Protein kinase, mitogen-activated 4
R
Radical surgery 53
Raloxifene 68
Ramakrishna experience 35fc
Randomized controlled trial 39, 75
Rectal
aqueous contrast 51
evaluation 52
excision 45
mobilization 43f
mucosa 52
submucosa 52
Rectovaginal nodule, excision of 43f
Rectovaginal septum
endometriosis of 44, 45f
lesions 50
Rectovaginal space 51
Rectum 45
Renal agenesis 30
Retrograde menstruation 48
Sampson's theory of 2
Retroperitoneal lesions, subclassification of 50
Robert's uterus 33
hysteroscopic
resection of 34f
view of 34f
laparoscopic view of 34f
magnetic resonance imaging of 34f
relook hysterscopic view of 34f
ultrasonography of 33f
S
Saline, normal 42
Sampson's theory 2, 48, 62
Scar endometriosis 62, 64
therapy of 63
Selective estrogen receptor modulator 11, 68
Selective progesterone receptor modulators 20, 68
Septa 67
fibrin 14
Septate
cervix 29
uterus 29, 30, 34
Septostomy 32
Simvastatin 68
Soft tissue sarcoma 63
Sonography
high-frequency 52
transvaginal 1f, 14, 67
Sperm inactivation 66
Statins 21
Stroma 1, 48
leads 49
Subfertility 6
Surface endometriosis 48
electrocoagulation 9f
Surgery 70
conservative 26, 53
endometriotic 42
laparoscopic 62
Surgical therapy
advantages of 70t
disadvantages of 70t
T
Tanner system 7
Tenesmus 49
Thromboembolism, risk of 18
Tissue
adenomyomatous 27
adenomyotic 27
endometrial 48, 67
endometriotic 32
ovarian 58
Torus uterinus 49
Transverse vaginal septum 29, 30
Triptorelin 69
Tubal motility 66
Tubes, anatomical distortion of 66
Tumor necrosis factor 3
alpha blockers 21
U
Ultra-long protocol 38
Ultrasonography 63, 67
three-dimensional 31, 67
transrectal 50-52
Ureter, endometriosis of 42, 46, 53
Ureteral involvement 49, 52
Ureteric dissection 43f
Urinary bladder, endometriosis of 42, 46
Urinary tract
disease 51
endometriosis 48
Uterine
agenesis 30
anomaly 29
nonobstructive 31
cavity 27, 48
didelphys 33f
fibroid 74
incision 27
Uterosacral ligament 1, 2f, 45, 49-53, 62
Uterovaginal agenesis 29
Uterus
arcuate 29, 30
asymmetric
dissection of 27
enlarged 25
bicornuate 29, 34
bicorporeal 29
carina of 49
didelphys 29, 30, 32, 34
distension of 31
dysmorphic 29
normal 29
right horn of 33f
unicornuate 29, 30, 34
V
Vagina 50, 51
distension of 31
normal 29
Vaginal
agenesis 30
anomaly 29
aplasia 29
excision 43
fornix, posterior 49
injection 51
septa 31
septum, longitudinal
nonobstructing 29
obstructing 29
Valproic acid 68
Vascular
dissemination theory 48
endothelial growth factor 3
theory 2
×
Chapter Notes

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FOGSI FOCUS Endometriosis: Current Trends
FOGSI FOCUS Endometriosis: Current Trends
Editor-in-Chief Nandita Palshetkar MD FCPS FICOG FRCOG (UK) President of FOGSI 2019 Scientific Director, Bloom IVF Professor of Obstetrics and Gynecology Dr DY Patil Medical College, Hospital and Research Centre Navi Mumbai, Maharashtra, India Editor Kuldeep Jain MD Fellow ART (Singapore) IVF Consultant and Gynae Laparoscopic Surgeon Director, KJIVF and Laparoscopy Centre, Delhi Chairperson, Endometriosis Committee Co-Editors Sudha Prasad MBBS MS FICOG FICMCH IVF Coordinator at IVF and Reproductive Biology Centre Department of Obstetrics and Gynecology Lok Nayak Hospital and Maulana Azad Medical College Delhi, India T Ramani Devi MD DGO FICS FICOG Consultant, Obstetrician & Gynaecologist and Reproductive Medicine Vice President Elect, South Zone FOGSI 2020 Department of Obstetrics and Gynaecology Ramakrishna Medical Centre LLP Trichy, Tamil Nadu, India Louis T Fessy DGO DNB FAGE MNAMS DPS MICOG FICOG Senior Consultant and Associate Professor Department of Reproductive Medicine and Surgery Amrita Fertility Centre, AIMS Amrita Institute of Medical Sciences Kochi, Kerala, India
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FOGSI FOCUS Endometriosis: Current Trends
First Edition: 2020
9789389188844
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Office Bearers of Team FOGSI 2019
President
Secretary General
Vice President (West Zone)
Vice President (West Zone)
Vice President (North Zone)
Vice President (East Zone)
Vice President (South Zone)
Deputy Secretary General
Treasurer
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lmmediate Past President
President Elect
Dr Nandita Palshetkar
Dr Jaydeep Tank
Dr Rajendrasingh Pardeshi
Dr Haresh Doshi
Dr Sudha Prasad
Dr Rajat Mohanty
Dr Aswath Kumar
Dr Madhuri Patel
Dr Suvarna Khadilkar
Dr Parikshit Tank
Dr Ameya Purandare
Dr Jaideep Malhotra
Dr Alpesh Gandhi
Chairpersons of the Committees
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International Academic Exchange
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Dr Girish Mane
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Dr Pratik Tambe
Dr Kuldeep Jain
Dr B Ramesh
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Dr Shobha Gudi
Dr Vidya Thobbi
Dr Mandakini Pradhan
Dr Mrutyunjay Mohapatra
Dr Meenu Agarwal
Dr Asha Baxi
Dr Varsha Baste
Dr Bharti Maheshwari
Dr Abha Singh
Dr Komal Chavan
Dr Rajendra Nagarkatti
Dr Bhagyalaxmi Nayak
Dr Vaishali Chavan
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Dr Sebanti Goswami
Dr N Palaniappan
Dr Sneha Bhuyar
Dr Sudha Tandon
Dr Nita Thakre
Dr Vinita Singh
Contributors President's Message
My Dear FOGSI Members
Greetings from FOGSI !
Endometriosis affects an estimated 10 to 15% of the female population. It has various presentations and degrees of severity. In its most severe form this disease is very debilitating for patients, compromising not just their fertility but also their social, professional, and personal life. It has become a major public health problem associated with high monetary costs and a significant decline in productivity. Endometriosis is not acknowledged in society, and hence is underdiagnosed and so is undertreated.
This FOGSI Focus on endometriosis is a welcome addition to all the literature available on endometriosis. It provides a balanced blend of all aspects of endometriosis like history and a discourse on pathogenesis, along with descriptions of clinical symptomatology, medical and surgical therapeutic approaches, and offers suggestions for holistic care of patients.
The editor of this FOGSI Focus Dr Kuldeep Jain and Co-editors, Dr Sudha prasad, Dr Ramani Devi and Dr Fessy Luice T have compiled a publication on endometriosis which is holistic and will provide us with a practical and evidence-based approach which will be of great value to clinicians and trainees.
Nandita Palshetkar
President, FOGSI
Preface
“He who knows Endometriosis, knows Gynecology
—Sir William Osler
Endometriosis is a common and debilitating condition that can have a significant impact on the quality of life of the sufferer. It is a disease of controversy/complexity, chronic/multi–factorial, progressive/recurrent, not malignant but behaves like one and difficult to diagnose and treat. Once diagnosed clinically and by various imaging modalities, there is a wide variation of interventions available for treatment ranging from ovarian suppression with hormonal agents to radical excisional surgery. This suggests that the condition is heterogeneous and that there is a lack of consensus over optimal management. Laparoscopy remains gold standard and is the best tool for diagnosis, treatment and follow-up evaluation of endometriosis. Endometriosis affects over 176 million women worldwide and 6–10% of women of reproductive age are affected. An incidence of 2.37–2.49/1000 has also been reported with a relative prevalence of 6–8% in the general population. There is a higher incidence of infertile women. 25% of patients undergoing ART are affected and 20–40% of these patients show ovarian endometriosis.
It is estimated that 25–35% of infertile women have endometriosis while 30–50% of women with endometriosis have infertility. Eight per cent of women in ART programs have the primary diagnosis of endometriosis made. In a review of 61 women with endometriosis 48 of which underwent controlled ovarian hyperstimulation showed the need for higher total dose or ampoules of gonadotropins to produce an average of 3 metaphase II eggs, 50% fertilization rate but pregnancy rates were lower in those with moderate to severe disease. Fecundability is 0.20 in unaffected women but 0.02–0.20 in women with endometriosis. Another report indicates a fecundity of 0.15–0.20 per month in normal couples but 0.02–0.10 in untreated women with endometriosis and infertility. Therefore in women with stage III-IV monthly probability to conceive is 2–10% vs. 15–25% in healthy couples.
Choice of management depends on the presenting symptoms, age, fertility history and progression and recurrence. If the primary symptom is pain and fertility is not the issue, definitive surgery with as much cytoreduction is possible is the treatment of choice, however if the fertility is the issue or patient is young, a conservative approach is recommended. Medical treatments that inhibit ovulation have been found to be effective in reducing pain in 80–90% of women. Medical therapy, however, is not cytoreductive and pain recurrence is frequent after treatment withdrawal. Moreover, side effects and costs discourage long-term use and it does not improve pregnancy rates in women with associated infertility.
For generations it has been taught that abdominal hysterectomy and removal of both ovaries is the definitive surgery for endometriosis. However, our understanding of the disease has evolved. Technological advances in camera optics and electrosurgical devices and improved surgical experience, combined with the limitations of medical treatment, now make operative laparoscopy the preferred management choice for a considerable proportion of women.
In vitro fertility (IVF) is the appropriate treatment especially in the presence of tubal function compromise, male factor or failure of other treatments. IVF is an effective treatment in women with infertility and endometriosis. IVF is appropriate treatment especially if there are multiple causes of infertility and/or other treatments have failed. Surgery may have some role in mild endometriosis and cases with large endometriomas as surgical treatment may improve outcomes. IVF is a useful and effective procedure to treat infertile women with endometriosis although its success rate could be impaired by the disease itself. If there is a negative effect, the oocyte quality more than the endometrium seems to be affected, this may explain why outcomes are better in women with endometriosis who have recipient cycles. Some large data bases did not show adverse effect on pregnancy rates (SART and HFEA) in women with endometriosis.
Considering the complex nature of endometriosis, dilemmas debates and controversies involved in the diagnosis, management and follow-up, and newer suggested molecules for medical management as well as changing concepts for improving the fecundity and cumulative pregnancy rates in ART. This edition of FOGSI FOCUS is planned to cover all areas from diagnosis, etiopathology to advances in medical management to managing deep infiltrative endometriosis to different newer stimulation protocols and fertility preservation and decision making in infertile couples, and I am happy that all contributors have put in their best effort to compile various chapters in such a way that they are clinically useful and easy to understand.
I am thankful to FOGSI president Dr Nandita Palshetkar for giving me the opportunity to bring this FOGSI FOCUS in my last working year as chairperson, endometriosis committee. I am also thankful to my Co-editors Dr Sudha Prasad, Dr Ramani Devi and Dr Fessy Louise T for giving there valuable inputs to complete this work in time. I acknowledge the timely submission of very high quality academic material by all contributing authors.
I express my deep appreciation to Dr Prateek Tambe for extending all possible help to bring out this work in time.
I will be only too happy if the chapters in this volume of FOGSI focus are of benefit to all practicing gynecologist of country in helping to treat all endometriosis patients coming to them for help.
Kuldeep Jain