Laparoscopic Assessment of the Ovaries after Resolving the Endometriomas with Ultrasound-guided Transvaginal Ethanol Sclerotherapy

The first case presented a 33-year-old patient with a history of endometriosis and depression, who suffered from dysmenorrhea and dyspareunia. The patient had never been pregnant due to infertility, and she wished to conceive a child. She was qualified for ultrasound-guided transvaginal ethanol sclerotherapy of an endometrioma of the left ovary. In the ultrasound examination, the lesion measured 28 mm × 23 mm, and the sliding sign was normal. The CA-125 level was 24.5 U/mL. During sclerotherapy, 8 mL of the cyst content was aspirated. After flushing, 5 mL of ethanol was instilled in the cyst and then aspirated. Histopathological examination revealed the endometrioma. Another cyst of the right ovary was not resolved due to unfavorable transvaginal access. The patient received hormonal therapy after sclerotherapy. One month after sclerotherapy, the patient was qualified for laparoscopic myomectomy and ovarian cystectomy. During the surgery, two subserosal myomas with a diameter of approximately 30 mm and 15 mm were enucleated, and the right ovarian endometriotic cyst was excised. Histopathology confirmed an endometrioma. No pathological changes were observed in the pelvic cavity, and the normal anatomy of the left ovary has been preserved [ Figure 1a and b ]. The patient was classified as stage III endometriosis according to the revised American Society for Reproductive Medicine (rASRM) classification staging system. In the ENZIAN score, the patient received the following result: (s)O0/2. Laparoscopic images of the ovaries (a and b) in case 1, (c) in case 2 This patient was a 31-year-old woman with no history of chronic diseases besides endometriosis, who experienced dysmenorrhea. She underwent laparoscopic cystectomy for an endometrioma of the left ovary 7 years earlier. She suffered from infertility and had no obstetric history so far. She wanted to get pregnant in the future. The patient was diagnosed with an endometrioma of the right ovary measuring 55 mm × 43 mm. The sliding sign was negative in the ultrasound examination. Preprocedural CA-125 level was 31.60 U/mL. The patient underwent ultrasound-guided transvaginal ethanol sclerotherapy of the right ovarian endometrioma. During the procedure, 18 mL of the cyst fluid was aspirated, and then 10 ml of ethanol was instilled into the cyst. In the histopathological examination results, endometrioma was confirmed. Hormonal treatment was not implemented after sclerotherapy. Besides pain symptoms, the patient suffered from infertility. Since the Hystero Salpingo-Contrast Sonography (HyCoSy) performed 3 months later showed obstructed fallopian tubes, 7 months after sclerotherapy, the laparoscopic tubal patency test was conducted as a part of a further diagnostic pathway. The patency of both fallopian tubes was confirmed. In addition, peritoneal foci of endometriosis were found. Both ovaries had normal anatomical structures and were not covered by adhesions [ Figure 1c ]. Nonserious adhesions in the rectouterine pouch were found. The patient was found to have rASRM-defined stage II endometriosis and was classified as (s) P2, T+/+ according to ENZIAN. This patient was a 31-year-old woman with a history of endometriosis and Hashimoto’s disease, suffering from painful and hemorrhagic menstruation. She had never been pregnant due to infertility, but had procreation plans. The patient was diagnosed with three endometriomas, one in the left ovary measuring 35 mm × 28 mm, and two in the right ovary, measuring 32 mm × 27 mm and 30 mm × 29 mm. In the ultrasound, the sliding sign was present. The preoperative level of CA-125 reached 30.8 U/mL. The patient was qualified for ultrasound-guided transvaginal ethanol sclerotherapy of all endometriomas. During sclerotherapy, 12 mL of cyst fluid was aspirated from the left ovarian endometrioma, and 18 mL and 12 mL from the right ovarian endometriomas. The lesions were resolved by administering 7 mL, 10 mL, and 7 mL of ethanol, respectively. Histopathological examination revealed the presence of endometriomas. The patient did not receive hormonal therapy after sclerotherapy. The indication for laparoscopy, performed 1 month after the sclerotherapy, included the diagnosis of blocked fallopian tubes, which was made 2 weeks after sclerotherapy during HyCoSy. During the laparoscopic tubal patency test, the patency of both fallopian tubes was confirmed. In addition, the recurrence of the endometriotic cyst of the right ovary was found, and the lesion was excised. Histopathological examination confirmed the endometrioma. Macroscopically, the left ovary had a normal structure, and no adhesions in the pelvic cavity were found [ Figure 2a -c]. A single focus of endometriosis on the peritoneum was observed. The patient was found to have rASRM-defined stage III endometriosis. The patient was evaluated as (s) P1, O0/2, T+/+ according to ENZIAN classification. Laparoscopic images of the ovaries (a-c) in case 3, (d-f) in case 4 Another case describes a 29-year-old patient with no chronic diseases except endometriosis, preoperatively diagnosed with an endometrioma of the left ovary. The patient had no obstetric history. In the ultrasound examination, the ovarian endometriotic cyst measured 32 mm × 27 mm, and the sliding sign was observed. The preprocedural serum CA-125 level was 24.4 U/mL. The patient was admitted for ultrasound-guided transvaginal ethanol sclerotherapy of the lesion. The content of the 20 mL ovarian cyst was removed, and 12 mL of ethanol was injected into the cyst cavity. The histopathological assessment found the endometrioma. The patient had no pain symptoms; however, she had suffered from infertility for a year and a half, and she wished to conceive. The patient did not receive hormonal therapy after sclerotherapy. Two months after the procedure, the patient underwent HyCoSy, and the right tubal blockage was diagnosed. Thus, 3 months after sclerotherapy, a laparoscopic tubal patency test was performed, and both fallopian tubes were found to be patent. In addition, small foci of endometriosis were found on the peritoneum of the recto-uterine pouch. Besides that, the normal anatomy of the pelvis was preserved, and no adhesions were observed [ Figure 2d -f]. The patient was staged as stage I endometriosis according to the rASRM staging system and received a (s) P1, T+/+ score on the ENZIAN scale. Table 1 summarizes the basic characteristics and clinical course of all patients. Summary of patients’ general information, procedure details, and outcomes for cases undergoing laparoscopies preceded by ultrasound-guided transvaginal ethanol sclerotherapies BMI: Body mass index

Ultrasound-guided transvaginal ethanol sclerotherapy is a minimally invasive procedure for ovarian endometrioma treatment. It involves injecting a sclerosing agent, ethanol, into the cyst cavity after transvaginal aspiration of the cyst content under ultrasound guidance.[ 1 2 ] As this method does not result in a decrease of ovarian reserve, it may be considered as an alternative to surgery for women who wish to preserve their fertility. Potential complications of sclerotherapy include abscess formation, abdominal pain, and fever; however, current literature does not mention adhesion formation as one of them.[ 3 4 ] So far, only one report has focused on the appearance of the pelvic cavity after this procedure. They observed the presence of advanced adhesions in the pelvis related to sclerotherapy.[ 5 ] Considering that adhesions significantly impair fertility, such reports are very alarming.[ 6 ] Hence, in response, we present laparoscopic findings in four patients who had previously undergone ultrasound-guided transvaginal ethanol sclerotherapy for ovarian endometriomas.

Presented cases demonstrated that ultrasound-guided transvaginal ethanol sclerotherapy, proposed by Miquel et al .,[ 1 ] performed without complications, did not result in enhanced adhesion formation and impaired ovary morphology. Thus, our cases proved that this minimally invasive endometrioma management did not disturb the anatomy of the pelvis and might be suitable for patients trying to conceive. Our observations refute the conclusions formulated in the previous study.[ 5 ] The laparoscopic findings presented by Okagaki et al . were contradictory, showing severe pelvic adhesions, particularly affecting the ovaries. The authors indicated ethanol as a promoter of excessive adhesion formation.[ 5 ] Their results would suggest that ethanol sclerotherapy induces adhesions and, thus, disrupts pelvic anatomy and may have a negative effect on fertility.[ 5 7 ] The report by Okagaki et al . is not free of some limitations. Unfortunately, they did not specify details such as the interval between the two procedures or possible adverse events during sclerotherapy. Therefore, the complication in the form of undesirable ethanol extravasation into the pelvic cavity cannot be excluded.[ 5 ] Although no reports suggest an association between ethanol action and adhesion formation, considering the sclerosant effects of ethanol, such a complication cannot be excluded.[ 2 ] On the other hand, the results of another study have also proposed that adhesion formation may be the result of tissue trauma caused by transvaginal endometrioma puncture. Muzii et al . compared the laparoscopic findings between 13 patients who previously underwent transvaginal aspiration of endometriomas without administering a sclerosant agent and 42 patients with no prior intervention. Increased adhesion formation was observed in the group that underwent aspiration compared to the untreated group.[ 8 ] In addition, Okagaki et al . did not provide images obtained during laparoscopy. Hence, it is difficult to assess the gravity of adhesion formation objectively.[ 5 ] Moreover, endometriomas often coexist with adnexal adhesions.[ 9 ] Therefore, it is not possible to exclude the existence of adhesions before the surgery.[ 5 ] It is also important to point out some limitations of our case series. First, only four case reports have been described. Therefore, they were probably not representative observations for all patients undergoing ultrasound-guided transvaginal ethanol sclerotherapy. Secondly, there was a lack of case reports describing laparoscopic surgery performed more than a few months after sclerotherapy. Thus, the long-term effects of sclerotherapy on pelvic anatomy cannot be inferred. In addition, the described cases have not reported any ovarian reserve measures such as anti-Müllerian hormone levels, follicle-stimulating hormone levels, or antral follicle count. Hence, an in-depth assessment of the reproductive potential among patients who underwent sclerotherapy is not possible.[ 10 ] The findings of our case series demonstrated no adverse effects of sclerotherapy on ovarian morphology. These observations may encourage clinicians to use this treatment method more often. Future research should report not only ovarian and pelvic cavity appearances but also laboratory and ultrasound indicators of ovarian reserve in patients with a history of ultrasound-guided transvaginal ethanol sclerotherapy. In sum, the presented case reports indicate that ultrasound-guided transvaginal ethanol sclerotherapy did not induce excessive adhesion formation in the pelvic cavity. Thus, it can be concluded that this treatment method probably does not impair fertility by this mechanism. Conceptualization, ID and GP; Methodology, ID, KF, and GP; Software, ID, KF, SM, MA and GP; Validation, ID and GP; Formal Analysis, ID; Investigation, ID and KF; Resources, ID, KF, SM, MA and GP; Data Curation, PS and GP; Writing – Original Draft Preparation, KF, MA and SM; Writing – Review and Editing, ID, MA, EW, PS and GP; Visualization, GP; Supervision, GP; Project Administration, ID and GP; Funding Acquisition, GP. All authors have read and agreed to the final version of the manuscript. Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study. There are no conflicts of interest.

The following ultrasound-guided transvaginal ethanol sclerotherapy details were applied in all described cases. The risk of malignancy was ruled out in the preprocedural ultrasound examination performed by a trained gynecologist. In addition, serum Ca-125 levels were measured in all patients. Patients gave written informed consent to the procedure. Sclerotherapy was performed under general anesthesia in the lithotomy position. Under transvaginal ultrasound guidance, cysts were punctured with a 16-gauge needle (Needle 16G mm × 330 mm for Oocyte/Ovarian cyst aspiration Monolume; Rimos, Mirandola, Italy). The entire volume of the cyst content was aspirated and sent for histopathological evaluation. Then, the cyst cavity was flushed with saline until clear fluid was obtained, and approximately 60% of the initial cyst volume was filled with 96% ethanol. The alcohol was left for 10 min and then drained. All procedures were performed without any complications. The presence of macrophages, siderophages, and protein masses in the histopathological evaluation confirmed an endometrioma. All patients gave informed written consent to the publication of their cases.