{"paper_id":"3cc9f101-6149-41a8-899f-96bcee2aff0c","body_text":"Abstract\nObjective\nTo determine the efficacy and safety of ultrasound (US)-guided sclerotherapy for the treatment of ovarian endometrioma through a systematic review and meta-analysis.\nMethods\nMEDLINE and EMBASE databases were searched for studies reporting outcomes in patients with endometrioma who were treated with US-guided sclerotherapy. Meta-analyses of recurrence, pain resolution, pregnancy, technical success, and complication rates were analyzed. Subgroup analyses were conducted regarding the indwelling time of sclerotherapy (≤ 10 min vs > 10 min).\nResults\nTwenty-eight studies (1301 patients) were included. The pooled technical efficacy was 98.3%. The pooled estimates of recurrence, pain resolution, and pregnancy rate were 13.8%, 85.9%, and 37.6%, respectively. The pooled major complication rate was 1.7%. A sclerotherapy time > 10 min had a lower pooled recurrence rate than a time ≤ 10 min (11.2% vs 20.9%; p = 0.106). Direct comparisons showed that the recurrence rate was significantly lower with sclerotherapy > 10 min than with sclerotherapy ≤ 10 min (OR, 0.2; p = 0.015). Regarding pregnancy rates, sclerotherapy of > 10 min showed no significant difference compared with sclerotherapy of ≤ 10 min (35.9% vs 38.8%; p = 0.664). Direct comparisons with surgery showed that sclerotherapy increased the pregnancy rate compared with surgery (OR, 2.0; p = 0.042). There was no significant difference in AMH level before and after sclerotherapy (p = 0.951). There was no significant difference in major complication rates between sclerotherapy > 10 min and ≤ 10 min (p = 0.837).\nConclusion\nUS-guided sclerotherapy seems to be an effective and safe therapeutic option regarding recurrence, pain resolution, and pregnancy for patients with ovarian endometrioma.\nKey Points\n• US-guided sclerotherapy seems to be an effective and safe therapeutic option regarding recurrence, pain resolution, and pregnancy for patients with ovarian endometrioma.\n• Sclerotherapy of more than 10 min had a lower recurrence rate than sclerotherapy less than or equal to 10 min. There was no significant difference in major complication rates between sclerotherapy of > 10 min and ≤ 10 min.\n• Future randomized controlled trials are warranted to compare the outcomes of US-guided sclerotherapy with surgery.\nSimilar content being viewed by others\nAbbreviations\n- AMH:\n-\nAnti-Müllerian hormone\n- ART:\n-\nAssisted reproductive technology\n- CDS:\n-\nCatheter-directed sclerotherapy\n- CI:\n-\nConfidence interval\n- OR:\n-\nOdds ratio\n- RCT:\n-\nRandomized controlled trial\n- US:\n-\nUltrasonography\nReferences\nBurney RO, Giudice LC (2012) Pathogenesis and pathophysiology of endometriosis. Fertil Steril 98:511–519\nKoninckx PR, Meuleman C, Demeyere S, Lesaffre E, Cornillie FJ (1991) Suggestive evidence that pelvic endometriosis is a progressive disease, whereas deeply infiltrating endometriosis is associated with pelvic pain. Fertil Steril 55:759–765\nBusacca M, Riparini J, Somigliana E et al (2006) Postsurgical ovarian failure after laparoscopic excision of bilateral endometriomas. Am J Obstet Gynecol 195:421–425\nCelik HG, Dogan E, Okyay E et al (2012) Effect of laparoscopic excision of endometriomas on ovarian reserve: serial changes in the serum antimüllerian hormone levels. Fertil Steril 97:1472–1478\nChang HJ, Han SH, Lee JR et al (2010) Impact of laparoscopic cystectomy on ovarian reserve: serial changes of serum anti-Müllerian hormone levels. Fertil Steril 94:343–349\nErcan CM, Sakinci M, Duru NK, Alanbay I, Karasahin KE, Baser I (2010) Antimullerian hormone levels after laparoscopic endometrioma stripping surgery. Gynecol Endocrinol 26:468–472\nRaffi F, Metwally M, Amer S (2012) The impact of excision of ovarian endometrioma on ovarian reserve: a systematic review and meta-analysis. J Clin Endocrinol Metab 97:3146–3154\nMuzii L, Achilli C, Lecce F et al (2015) Second surgery for recurrent endometriomas is more harmful to healthy ovarian tissue and ovarian reserve than first surgery. Fertil Steril 103:738–743\nAkamatsu N, Hirai T, Masaoka H, Sekiba K, Fujita T (1988) Ultrasonically guided puncture of endometrial cysts–aspiration of contents and infusion of ethanol. Nihon Sanka Fujinka Gakkai Zasshi 40:187–191\nHan K, Seo SK, Kim MD et al (2018) Catheter-directed sclerotherapy for ovarian endometrioma: short-term outcomes. Radiology 289:854–859\nNoma J, Yoshida N (2001) Efficacy of ethanol sclerotherapy for ovarian endometriomas. Int J Gynaecol Obstet 72:35–39\nIkuta A, Tanaka Y, Mizokami T et al (2001) (2006) Management of transvaginal ultrasound-guided absolute ethanol sclerotherapy for ovarian endometriotic cysts. J Med Ultrason 33:99–103\nAgostini A, De Lapparent T, Collette E, Capelle M, Cravello L, Blanc B (2007) In situ methotrexate injection for treatment of recurrent endometriotic cysts. Eur J Obstet Gynecol Reprod Biol 130:129–131\nHsieh CL, Shiau CS, Lo LM, Hsieh TT, Chang MY (2009) Effectiveness of ultrasound-guided aspiration and sclerotherapy with 95% ethanol for treatment of recurrent ovarian endometriomas. Fertil Steril 91:2709–2713\nGarcía-Tejedor A, Castellarnau M, Ponce J, Fernández ME, Burdio F (2015) Ethanol sclerotherapy of ovarian endometrioma: a safe and effective minimal invasive procedure. Preliminary results. Eur J Obstet Gynecol Reprod Biol 187:25–29\nGarcia-Tejedor A, Martinez-Garcia JM, Candas B et al (2020) Ethanol sclerotherapy versus laparoscopic surgery for endometrioma treatment: a prospective, multicenter, cohort pilot study. J Minim Invasive Gynecol 27:1133–1140\nKoo JH, Lee I, Han K et al (2021) Comparison of the therapeutic efficacy and ovarian reserve between catheter-directed sclerotherapy and surgical excision for ovarian endometrioma. Eur Radiol 31:543–548\nLee KH, Kim CH, Lee YJ, Kim SH, Chae HD, Kang BM (2014) Surgical resection or aspiration with ethanol sclerotherapy of endometrioma before in vitro fertilization in infertilie women with endometrioma. Obstet Gynecol Sci 57:297–303\nMiquel L, Preaubert L, Gnisci A et al (2020) Endometrioma ethanol sclerotherapy could increase IVF live birth rate in women with moderate-severe endometriosis. PLoS One 15:e0239846\nAflatoonian A, Tabibnejad N (2020) Aspiration versus retention ultrasound-guided ethanol sclerotherapy for treating endometrioma: a retrospective cross-sectional study. Int J Reprod Biomed 18:935–942\nShawki HE (2012) The impact of in situ methotrexate injection after transvaginal ultrasound-guided aspiration of ovarian endometriomas on ovarian response and reproductive outcomes during IVF-cycles. Middle East Fertil Soc J 17:82–88\nFisch JD, Sher G (2004) Sclerotherapy with 5% tetracycline is a simple alternative to potentially complex surgical treatment of ovarian endometriomas before in vitro fertilization. Fertil Steril 82:437–441\nKoike T, Minakami H, Motoyama M, Ogawa S, Fujiwara H, Sato I (2002) Reproductive performance after ultrasound-guided transvaginal ethanol sclerotherapy for ovarian endometriotic cysts. Eur J Obstet Gynecol Reprod Biol 105:39\nYazbeck C, Madelenat P, Ayel JP et al (2009) Ethanol sclerotherapy: a treatment option for ovarian endometriomas before ovarian stimulation. Reprod Biomed Online 19:121–125\nAndré GM, Vilarino FL, Christofolini DM, Bianco B, Barbosa CP (2011) Aspiration and ethanol sclerotherapy to treat recurrent ovarian endometriomas prior to in vitro fertilization - a pilot study. Einstein (Sao Paulo) 9:494–498\nAlbanese G, Kondo KL (2010) Pharmacology of sclerotherapy. Semin Intervent Radiol 27:391–399\nCohen A, Almog B, Tulandi T (2017) Sclerotherapy in the management of ovarian endometrioma: systematic review and meta-analysis. Fertil Steril 108:117-124.e115\nLiberati A, Altman DG, Tetzlaff J et al (2009) The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. Ann Intern Med 151:W65-94\nNational Heart, Lung, and Blood Institute Quality Assessment Tool for Case Series Studies. National Heart, Lung, and Blood Institute, Bethesda. Available via https://www.nhlbi.nih.gov/health-topics/study-quality-assessment-tools. Accessed 20 Feb 2021\nAlborzi S, Namavar Jahromi B, Ahmadbeigi M (2018) Recovery rate of patients with recurrent ovarianendometriomas using sclerotherapywith 95% ethanol. J Obstet Gynecol Cancer Res 3:105–110\nFei D, Li Y, Sui G (2018) Clinical study of ultrasound-guided puncture lauromacrogol sclerosis in the treatment of ovarian endometriosis cyst. AIP Conf Proc 2036:030009\nChang CC, Lee HF, Tsai HD, Lo HY (1997) Sclerotherapy–an adjuvant therapy to endometriosis. Int J Gynaecol Obstet 59:31–34\nMessalli EM, Cobellis G, Pecori E et al (2003) Alcohol sclerosis of endometriomas after ultrasound-guided aspiration. Minerva Ginecol 55:359–362\nGatta G, Parlato V, Di Grezia G et al (2010) Ultrasound-guided aspiration and ethanol sclerotherapy for treating endometrial cysts. Radiol Med 115:1330–1339\nShawki HE, Elmorsi M, Samir A, Eissa MK (2011) In situ methotrexate injection after transvaginal ultrasound-guided aspiration of ovarian endometriomas: a randomized controlled trial. Middle East Fertil Soc J 16:224–231\nWang LL, Dong XQ, Shao XH, Wang SM (2011) Ultrasound-guided interventional therapy for recurrent ovarian chocolate cysts. Ultrasound Med Biol 37:1596–1602\nBegum MR, Ehsan M, Ehsan N, Begum Santa MS, Khan F, Sharmin F (2015) Sclerotherapy with ethanol: an effective and safe alternative to potentially complex surgical treatment of recurrent ovarian endometrioma. J South Asian Feder Obst Gynae 7:97–101\nWang SM, Cai HQ, Dong XQ et al (2015) Correlation between ovarian chocolate cyst and serum carbohydrate antigen 125 level and the effect of ultrasound-guided interventional sclerotherapy on serum carbohydrate antigen 125 level. J Obstet Gynaecol Res 41:92–98\nWu X, Xu Y (2015) Gestrinone combined with ultrasound-guided aspiration and ethanol injection for treatment of chocolate cyst of ovary. J Obstet Gynaecol Res 41:712–716\nWallace MJ, Chin KW, Fletcher TB et al (2010) Quality improvement guidelines for percutaneous drainage/aspiration of abscess and fluid collections. J Vasc Interv Radiol 21:431–435\nHiggins JP, Thompson SG, Deeks JJ, Altman DG (2003) Measuring inconsistency in meta-analyses. BMJ 327:557–560\nKim KW, Lee J, Choi SH, Huh J, Park SH (2015) Systematic review and meta-analysis of studies evaluating diagnostic test accuracy: a practical review for clinical researchers-part I. General guidance and tips. Korean J Radiol 16:1175–1187\nLee J, Kim KW, Choi SH, Huh J, Park SH (2015) Systematic review and meta-analysis of studies evaluating diagnostic test accuracy: a practical review for clinical researchers-part II. Statistical methods of meta-analysis. Korean J Radiol 16:1188–1196\nSterne JA, Egger M, Smith GD (2001) Systematic reviews in health care: Investigating and dealing with publication and other biases in meta-analysis. BMJ 323:101–105\nMesogitis S, Daskalakis G, Pilalis A et al (2005) Management of ovarian cysts with aspiration and methotrexate injection. Radiology 235:668–673\nKafali H, Eser A, Duvan CI, Keskin E, Onaran YA (2011) Recurrence of ovarian cyst after sclerotherapy. Minerva Ginecol 63:19–24\nSuganuma N, Wakahara Y, Ishida D et al (2002) Pretreatment for ovarian endometrial cyst before in vitro fertilization. Gynecol Obstet Invest 54(Suppl 1):36–40 (discussion 41-32)\nVercellini P, Crosignani PG, Abbiati A, Somigliana E, Viganò P, Fedele L (2009) The effect of surgery for symptomatic endometriosis: the other side of the story. Hum Reprod Update 15:177–188\nRossi AC, Prefumo F (2016) The effects of surgery for endometriosis on pregnancy outcomes following in vitro fertilization and embryo transfer: a systematic review and meta-analysis. Arch Gynecol Obstet 294:647–655\nMaignien C, Santulli P, Gayet V et al (2017) Prognostic factors for assisted reproductive technology in women with endometriosis-related infertility. Am J Obstet Gynecol 216:280.e281-280.e289\nPados G, Tsolakidis D, Assimakopoulos E, Athanatos D, Tarlatzis B (2010) Sonographic changes after laparoscopic cystectomy compared with three-stage management in patients with ovarian endometriomas: a prospective randomized study. Hum Reprod 25:672–677\nSalem HAM, Moustafa MZE, Abd Elnaby EA (2013) Large ovarian endometrioma: three – step procedure or combined excisional and ablative surgery. Fertil Steril 100:S74–S75\nKitajima M, Matsumoto K, Murakami N et al (2020) Ovarian reserve after three-step laparoscopic surgery for endometriomas utilizing dienogest: A pilot study. Reprod Med Biol 19:425–431\nChapron C, Marcellin L, Borghese B, Santulli P (2019) Rethinking mechanisms, diagnosis and management of endometriosis. Nat Rev Endocrinol 15:666–682\nAflatoonian A, Rahmani E, Rahsepar M (2013) Assessing the efficacy of aspiration and ethanol injection in recurrent endometrioma before IVF cycle: a randomized clinical trial. Iran J Reprod Med 11:179–184\nDunselman GA, Vermeulen N, Becker C et al (2014) ESHRE guideline: management of women with endometriosis. Hum Reprod 29:400–412\nDe Cicco NA, Carfagna P, De Cicco NC, Scambia G, Marana R, De Cicco NF (2020) Laparoscopic ethanol sclerotherapy for ovarian endometriomas: preliminary results. J Minim Invasive Gynecol 27:1331–1336\nAuthor information\nAuthors and Affiliations\nCorresponding author\nEthics declarations\nGuarantor\nThe scientific guarantor of this publication is Ji Hoon Shin.\nConflict of interest\nThe authors declare no competing interests.\nStatistics and biometry\nNo complex statistical methods were necessary for this paper.\nInformed consent\nWritten informed consent was not required for this study because this study is a systematic review and meta-analysis.\nEthical approval\nInstitutional review board approval was not required because this study is a systematic review and meta-analysis.\nMethodology\n• Meta-analysis.\n• Performed at one institution.\nAdditional information\nPublisher’s note\nSpringer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.\nGun Ha Kim and Pyeong Hwa Kim contributed equally to this work and share the first authorship.\nSupplementary Information\nBelow is the link to the electronic supplementary material.\nRights and permissions\nAbout this article\nCite this article\nKim, G.H., Kim, P.H., Shin, J.H. et al. Ultrasound-guided sclerotherapy for the treatment of ovarian endometrioma: an updated systematic review and meta-analysis. Eur Radiol 32, 1726–1737 (2022). https://doi.org/10.1007/s00330-021-08270-5\nReceived:\nRevised:\nAccepted:\nPublished:\nVersion of record:\nIssue date:\nDOI: https://doi.org/10.1007/s00330-021-08270-5","source_license":"CC0","license_restricted":false}