{"paper_id":"e39a6140-0116-443b-a49c-b35ea2e82fe4","body_text":"www.eCERM.orgCopyright © 2013. THE KOREAN SOCIETY FOR REPRODUCTIVE MEDICINE\n 29\nORIGINAL ARTICLE\nhttp://dx.doi.org/10.5653/cerm.2013.40.1.29\npISSN 2233-8233 · eISSN 2233-8241\nClin Exp Reprod Med 2013;40(1):29-32\nNatural conception rate following laparoscopic \nsurgery in infertile women with endometriosis\nHye Jun Lee 1 , Jae Eun Lee 2 , Seung-Yup Ku 2,3 , Seok Hyun Kim 2,3 , Jung Gu Kim 2 , Shin Y ong Moon 2,3 , Y oung Min Choi 2,3\n1 Maria Fertility Hospital, Seoul; 2 Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul; 3 Clinical Research \nInstitute, Seoul National University, Seoul, Korea\nObjective:  To investigate the influence of laparoscopic surgery on the natural conception rate in infertile women with endometriosis during \nthe first year after the operation.\nMethods:  We retrospectively studied 43 infertile women with surgically proven endometriosis. The natural conception rate was investigated \nfor the 12 months after the laparoscopy.\nResults:\n The overall pregnancy rate was 41.9% (18/43). 66.7% (12/18) and 94.4% (17/18) of the patients conceived within postoperative 3 months \nand 6 months, respectively. The spontaneous pregnancy rate was not associated with the severity of endometriosis or laparoscopic findings or \nthe type of surgery. The pregnancy rate for stage IV was relatively low (20.0%) compared to stage I, II, and III (35.7%, 44.4%, and 53.3%, respec -\ntively), although it did not reach statistical significance.\nConclusion:  Conservative surgical treatment with laparoscopy and a prompt attempt at natural conception may be effective for infertile pa -\ntients with endometriosis.\nKeywords:  Endometriosis; Infertility; Laparoscopy; Pregnancy rate\nIntroduction\nEndometriosis is a common gynecological disorder that results in \npelvic pain and infertility. The disease is known to affect approximate -\nly 10% to 15% of reproductive-aged women. When surgically inves -\ntigated in infertile women, evidence of endometriosis was found in \n30% of them, which rose to 50% if moderate-to-severe dysmenor -\nrhea was present [1]. An association between infertility and endome-\ntriosis, albeit controversial, has been frequently reported. Although \nthe mechanism by which endometriosis causes infertility remains \nunclear, several pathogenic mechanisms have been proposed, such \nas distorted anatomy in the pelvic cavity, a reduced quantity of func -\ntional ovarian tissue [2], and altered folliculogenesis [3]. \nThe role of surgery in the attempt to improve the pregnancy rate in \ninfertile women with endometriosis is much debated. Two random -\nized trials have compared laparoscopic surgical treatment of minimal \nand mild endometriosis with diagnostic laparoscopy only. Marcoux \net al. [4] reported that laparoscopic surgery enhanced their fecundity \nbut Gruppo Italiano [5] found no positive effect of surgery. The Euro -\npean Society of Human Reproduction and Embryology [6], the Amer -\nican Society for Reproductive Medicine (ASRM) [7], and the Royal \nCollege of Obstetricians and Gynaecologists [8] recommended sur -\ngery for stage I-II disease with limited benefit, and for stage III-IV dis -\nease with possible benefit. \nIn our previous study conducted from 1991 to 1998, the spontane-\nous conception rate during the 12 months after surgery was 48.5% \nReceived: Jan 17, 2013 ∙ Revised: Mar 8, 2013 ∙ Accepted: Mar 13, 2013\nCorresponding author:  Y oung Min Choi \nDepartment of Obstetrics and Gynecology, Seoul National University Hospital, \nSeoul National University College of Medicine, 101 Daehak-ro, Jongno-gu,  \nSeoul 110-744, Korea \nT el: +82-2-2072-2385  Fax: +82-2-762-3599  E-mail: ymchoi@snu.ac.kr\n*  This study was supported by a grant of the Korea Health 21 R&D Project, Ministry \nof Health & Welfare, Republic of Korea (01-PJ10-PG6-01GN13-0002).\nThis is an Open Access article distributed under the terms of the Creative Commons Attribution \nNon-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits \nunrestricted non-commercial use, distribution, and reproduction in any medium, provided the \noriginal work is properly cited.\n\n http://dx.doi.org/10.5653/cerm.2013.40.1.29\n Clin Exp Reprod Med 2013;40(1):29-32\n30\nand most of the conceptions took place during the first 3 months \npostoperatively [9]. As the number of subjects was small in the previ -\nous study, the present study was performed in a larger population in \na longer period of 18 years.\nMethods\nThe study subjects were recruited by review of medical records be-\ntween 1991 and 2009, from infertile women who underwent opera -\ntive laparoscopy at Seoul National University Hospital. The subjects \nfrom the previous study were also scrutinized and removed if ineligi -\nble. The eligibility criteria for recruitment were the following: age be-\ntween 20 and 39 years; infertility (at least 12 months of unprotected \nintercourse in unsuccessful attempts to become pregnant); regular \n24- to 35-day cycles; diagnosis of endometriosis based on surgical \nand histological criteria; no other infertility factors with confirmed bi -\nlateral tubal patency on hysterosalpingography; and no ovulatory \ndrug therapy or assisted reproductive technologies (ART) or hormone \ntherapy during postoperative 1 year. The review board for human re-\nsearch at the Seoul National University Hospital approved this proj -\nect, and written informed consent was obtained from each woman. \nLaparoscopies were performed under general anesthesia. The stage \nof disease was determined by the revised American Fertility Society \n(rAFS) classification of the ASRM [10]. The laparoscopic surgical treat -\nment involved the destruction or removal of all visible endometriotic \nimplants and the lysis of adhesions.\nThe occurrence, during one year after the laparoscopy, of an intra -\nuterine pregnancy was noted. The women’s age, body mass index \n(BMI), duration of infertility, CA-125 level, primary or secondary infer -\ntility, stage of endometriosis, laparoscopic findings, and type of sur -\ngery were compared between the pregnant and non-pregnant group. \nAll data analyses were performed using the SPSS ver. 12.0 (SPSS Inc., \nChicago, IL, USA). Fisher’s exact test and the Mann-Whitney U test \nwere used as appropriate. The significance level for all analyses was a \np-value of < 0.05.\nResults\nOne hundred fifty-four patients were diagnosed with endometrio -\nsis after a laparoscopic operation between 1991 and 2009. Twenty-\nseven patients were excluded for other infertility factors such as uter -\nine synechiae, male factors, ovulatory disorder, and conversion to \nlaparotomy. Forty-six patients received ART during the first postop -\nerative year, 5 patients were under hormonal treatment such as GnRH \nagonist, and 33 patients were lost to follow up. Of the 154 women, 43 \nwere eligible for assessment in this study and 18 patients (41.9%) suc -\ncessfully became pregnant during 1 year of natural ovulatory cycles.\nThe patients’  age, percentage of primary infertility, BMI, duration of \ninfertility, rAFS stage, and CA-125 level were similar in the pregnant \nand non-pregnant groups (Table 1). The median duration of days \nfrom surgery to the last menstrual period was 60 days ranging from \n1 to 270 days. 66.7% (12/18) and 94.4% (17/18) of the patients were \nconceived within postoperative 3 months and 6 months, respectively \n(Figure 1). \nThe pregnancy rates were 35.7%, 44.4%, 53.3%, and 20.0% for stage \nI, II, III, and IV, respectively (Table 2). Although there was no signifi -\ncant difference according to the AFS stages, the pregnancy rate for \nstage IV was relatively low (20.0%). \nOn laparoscopy, endometriomas were found in 22 patients, perit -\nubal/subovarian adhesion in 20 patients, posterior cul-de-sac (PCDS) \nobliteration in 9 patients, and superficial lesions only in 10 patients. \nThese findings as well as the types of surgery were not significantly \ndifferent between the pregnant and non-pregnant group (Tables 3, 4).\n \nTable 1.  Patient characteristics in pregnant and non-pregnant pa -\ntients\nPatient characteristics Pregnant patients \n(n = 18)\n Non-pregnant patients \n(n = 25)\nAge (yr) 30.7 ± 3.5 32.5 ± 3.8\nPrimary infertility (%) 66.7 64.0\nBody mass index (kg/m 2 ) 22.2 ± 2.5 20.9 ± 2.5\nDuration of infertility (mo) 32.5 ± 14.2 43.3 ± 31.3\nrAFS stage\nI-II 9 14\nIII-IV 9 11\nCA-125 (u/mL) 37.4 ± 43.2 21.2 ± 15.6\nValues are presented as means ± SD. \nNot significant for any of the parameters between the two groups using Fis -\nher’ s exact test and the Mann-Whitney U test.\nrAFS, the American Fertility Society revised classification of endometriosis.\nFigure 1.  Cumulative intrauterine pregnancy rate in the 12 months \nafter laparoscopy in women with endometriosis.\n100\n90\n80\n70\n60\n50\n40\n30\n20\n10\n0\nCumulative pregnancy rate (%)\nDays after laparoscopy\n0  30  60  90  120  150  180  210  240  270  300  330  360\n\nwww.eCERM.org\nHJ Lee et al.     Laparoscopic surgery in infertile women with endometriosis\n31\nDiscussion\nThe association between endometriosis and infertility has been \ngiven much attention; however, the role of surgery in enhancing \npregnancy rates remains elusive. In the present study, we retrospec -\ntively studied the natural conception rate of infertile women with \nendometriosis during one postoperative year and found that 41.9% \nof women successfully conceived without ART or hormone treatment. \nTo date, only two randomized controlled trials have studied wheth -\ner laparoscopic surgical treatment of minimal and mild endometrio -\nsis yielded a higher pregnancy rate than diagnostic laparoscopy only. \nMarcoux et al. [4] reported that in the 36 weeks after laparoscopic re-\nsection or ablation of endometriosis, the cumulative pregnancy rate \nwas 30.7%, compared with 17.7% in the controls. As a well-designed \ntrial engaging 172 patients, it provided a solid level of evidence sup -\nporting surgery for early stage endometriosis. Gruppo Italiano, on \nthe other hand, did not find a pregnancy rate in the resection/abla -\ntion group (24%) significantly different from the no treatment group \n(29%) [5]. As for deep infiltrating endometriosis, reported pregnancy \nrates range from 30% to 67%, with an overall weighted mean of \nabout 50%, which has been considered to be an overestimate due to \nselection bias and publication bias [11]. \nOur data were in agreement with the aforementioned findings \nshowing an average pregnancy rate of 41.9%, while the pregnancy \nrate for stage IV was lower than the average of the rest (stage I, 35.7%; \nstage II, 44.4%; stage III, 53.3%; and stage IV 20.0%). The pregnancy \nrates were not inversely proportional to the stages, which reflected \nthe inadequate predictive value of the AFS staging system with re -\ngard to the pregnancy rate [12,13]. In order to overcome the limit of \nthe current staging system, several predictive factors for the preg -\nnancy rate in infertile patients with endometriosis have been sug -\ngested, such as complete cul-de-sac obliteration [14] and peritubal/\novarian adhesion [15,16]. In our study, it is noteworthy that the PCDS \nobliteration and peritubal/subovarian adhesion was more frequently \nshown in the not-pregnant group, as opposed to the presence of en -\ndometrioma. In stage IV, all of the four patients who failed to con -\nceive had PCDS obliteration or peritubal/subovarian adhesion, where -\nas one patient who became pregnant did not. In addition, regardless \nof the stage, the not-pregnant group had more peritubal/subovarian \nadhesion and PCDS obliteration than the pregnant group, although \nit did not reach statistical difference partially due to the small num -\nber of patients. Further study on a larger number of patients is war -\nranted to clarify the role of peritubal/subovarian adhesion and PCDS \nobliteration in endometriosis-caused infertility.\nAccordingly, the need for radical interventions for rectovaginal le -\nsions has been proposed; however, it is questioned whether the effi -\ncacy outstripped the risk of major complications such as ureteral and \nrectal injuries. Douay-Hauser et al. [17] observed that extensive sur -\ngery for deep endometriosis in infertile women did not modify the \nTable 2.  Pregnancy rate according to the rAFS stage\nrAFS score Pregnancy rate\nStage Patients Pregnant %\nI 14   5 35.7\nII   9   4 44.4\nI+II 23   9 39.1\nIII 15   8 53.3\nIV   5   1 20.0\nIII+IV 20   9 45.0\nTotal 43 18 41.9\nNot significant for any of the parameters between the two groups using \nFisher’ s exact test. \nrAFS, the American Fertility Society revised classification of endometriosis.\nTable 3.  Laparoscopic findings in pregnant and non-pregnant pa -\ntients\nLaparoscopic finding Pregnant patients \n(n = 18)\nNon-pregnant patients \n(n = 25)\nEndometrioma 10 12\nUnilateral   6   9\nSmall a   1   2\nLarge b   5   7\nBilateral   4   3\nSmall a   2   1\nLarge b   2   2\nPeritubal/subovarian adhesion   7 13\nPCDS c  obliteration   2   7\nPartial   2   6\nComplete   0   1\nSuperficial lesion only   4   6\nNot significant for any of the parameters between the two groups using Fish -\ner’ s exact test.\nPCDS, posterior cul-de-sac.\na A small endometrioma was defined as less than 3 cm in diameter; b A large \nendometrioma was defined as equal to or larger than 3 cm in diameter.\nTable 4.  Laparoscopic procedure in pregnant and non-pregnant pa -\ntients\nLaparoscopic finding Pregnant patients \n(n = 18)\nNon-pregnant \npatients (n = 25)\nFulguration 16 19\nEndometrioma enucleation   7 11\nFenestration and fulguration   2   0\nUnilateral salpingo-oophorectomy   0   1\nAdhesiolysis   7 13\nMyomectomy   1   2\nNot significant for any of the parameters between the two groups using \nFisher’ s exact test.\n\n http://dx.doi.org/10.5653/cerm.2013.40.1.29\n Clin Exp Reprod Med 2013;40(1):29-32\n32\nglobal fertility outcome but was associated with a higher complica -\ntion rate. In addition, according to the review of Vercellini et al. [11], \nradical excision of rectovaginal endometriosis did not greatly im -\nprove reproductive prognosis.\nIn this study, most of the patients conceived within 6 months after \nthe surgery, as has generally been reported [4,16]. Somigliana et al. \n[18] observed that delaying conception after surgery was associated \nwith a lower pregnancy rate and a higher rate of recurrence of endo -\nmetriosis. Thus, after a thorough analysis of the patients’  reproductive \nstatus such as age, duration of infertility and other infertility causes, \nsurgery and a prompt attempt at natural conception with sufficient \ntime (at least six months) is advisable. \nIn conclusion, the present study shows that the natural conception \nrate was 41.9% during the first year after laparoscopic surgery in in -\nfertile women with endometriosis and no other factors. This informa -\ntion should be useful to infertile patients seeking treatment for en -\ndometriosis and the physicians counseling them.\nConflict of interest\nNo potential conflict of interest relevant to this article was reported.\nReferences\n1.  D’Hooghe TM, Debrock S, Hill JA, Meuleman C. Endometriosis \nand subfertility: is the relationship resolved? 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The factors \ninfluencing pregnancy after surgery in infertile patients with se-\nvere endometriosis. Korean J Obstet Gynecol 2005;48:2198-204.\n17.  Douay-Hauser N, Yazbeck C, Walker F , Luton D, Madelenat P , Kos -\nkas M. Infertile women with deep and intraperitoneal endome-\ntriosis: comparison of fertility outcome according to the extent \nof surgery. J Minim Invasive Gynecol 2011;18:622-8.\n18.  Somigliana E, Vercellini P , Daguati R, Giambattista E, Benaglia L, \nFedele L. Effect of delaying post-operative conception after con -\nservative surgery for endometriosis. Reprod Biomed Online 2010; \n20:410-5.","source_license":"CC0","license_restricted":false}