Fertility, pregnancy and severe endometriosis
We have just analysed our data on a subgroup of patients who have been attempting to conceive with severe endometriosis. Three surgeons with similar approaches to the treatment of endometriosis pooled their data and following excisional surgery (including bowel resection) we have an almost 75% chance of pregnancy. I reproduce the data that has been accepted to be presented at the World Congress of Endometriosis later this year below.
The data is in line with many anecdotal reports but has surpassed even our own expectations. Historically the belief has been that if you (unfortunately) have severe endometriosis and it is adequately excised the subsequent pregnancy rates dramatically improve. Conversely if your endometriosis is more minor, and less surgery is required to excise it the results are not as dramatic. Our current results again show extraordinary results with excisional surgery particularly with severe disease.
Clearly there are issues in relation to the degree of endometriosis that you have and the different perceptions of this between surgeons. I liken it to the game of “Chinese whispers”. If I whisper to you what I think is occurring and you then mention it to a number of other people the real story gets lost along the way. This is why images are so important.The experience of the team looking after you is also a significant factor.
I should emphasise that I do not believe the answer to endometriosis is surgery alone. Pregnancy, pseudo-pregnancy (with agents such as Mirena) or ovulation suppression are all critical in the ongoing management of the disorder.
We clearly need (and will) do more data (and life table) analysis, although these results are highly encouraging and I must admit to looking forward to going to the office at the moment….
FERTILITY OUTCOMES AFTER SURGERY FOR COLORECTAL ENDOMETRIOSIS AMONGST A COHORT OF WOMEN PRESENTING WITH INFERTILITY
H. J. Wills 1, M. J. Cooper 2, J. Tsaltas 3, L. Reyftmann 4, G. D. Reid 5,*
1Faculty of Medicine, University of New South Wales, 2Department of Obstetrics and Gynaecology, University of Sydney, Sydney, 3Monash Medical Centre, Melbourne, 4Sydney Women’s Endosurgery Centre, 5Liverpool Hospital, Sydney, Australia
Preferred Presentation Method: Oral or Poster Presentation
Has this abstract previously been presented or published?: No
Introduction: Fertility outcomes following surgery for colorectal endometriosis are an important consideration of the feasibility of such a management approach.
Objectives: To review the fertility outcomes of women who have undergone surgery for colorectal endometriosis with infertility as their primarily reason for initial presentation to a specialist.
Methods: The patient records of 3 gynaecologists were reviewed for patients who underwent 1 or more of segmental resection, disc excision or appendicectomy for endometriosis. Patients who had surgery after 30/08/10 were excluded to allow at least a 6 month follow-up period extending to 28/02/11. The patients’ primary reason for presentation to a specialist was determined. Information surrounding the duration of infertility and pregnancy outcomes after surgery was extracted from the records of those patients presenting with infertility.
Results: Seventy-five women presenting with either infertility (19/75; 25.3%) or pain and infertility (56/75; 74.7%) underwent surgery for colorectal disease. The average age of the cohort at the time of bowel surgery was 34 years and 7 months. Forty-three patients (57.3%) underwent segmental resection and 28 (37.3%) underwent disc excision. Four patients (5.4%) underwent simultaneous bowel procedures. Fertility data was unavailable for 7 women (9.3%).Amongst the 68 available for follow up, 11 women (16.2%) did not wish
to attempt conception post-operatively despite initially presenting with infertility as their primary complaint. This was found to be due to a variety of factors, including a change in circumstances surrounding partners, finances and desire for pregnancy. Fifty-seven women (83.8%) wished to conceive after surgery. Forty-two women successfully conceived, equating to a pregnancy rate of 73.6% (42/57) amongst those women wishing to conceive, and a rate of 61.8% amongst the cohort as a whole (42/68). A total of 54 pregnancies occurred. Fourteen (25.9%) were achieved spontaneously and 37 (68.5%) with assisted reproductive technologies. The mode of conception was unknown in 3 pregnancies (5.6%). The outcomes of 13 pregnancies (24.1%) remain unknown. Fourteen pregnancies (26.0%) resulted in miscarriage. Four pregnancies (7.4%) were on-going at the time of submission. Twenty-three pregnancies (42.53%) were known to have been successfully delivered; 15 by Caesarean section (65.2%), 7 vaginal deliveries (30.4%) and the method of delivery unknown in 1 (4.3%).
The cumulative pregnancy rate observed in this study is in keeping with fertility rates reported in the literature, which according to a recent systematic review, vary between 18% and 100%.1
Conclusion: The pregnancy rate observed in this series is considerably higher than previous studies of a similar nature, suggesting the potentially positive impact of colorectal endometriosis surgery upon fertility in those women with infertility as their primarily reason for presentation.
References: 1. De Cicco, et al. 2011. BJOG 118(3):285-91.
Disclosure of Interest: None Declared
Keywords: colorectal endometriosis, fertility outcomes, laparoscopy