Relationship between Patient Age and Disease Features in a Prospective Cohort of 1560 Women Affected by Endometriosis.

OBJECTIVE: To assess the relationship between age, location of the disease, and surgical procedures performed in patients undergoing surgical management of endometriosis. DESIGN: Retrospective study using data prospectively recorded in the North-West Inter Regional Female Cohort for Patients with Endometriosis database. SETTING: University tertiary referral center. PATIENTS: Women who underwent surgical management of symptomatic endometriosis between April 2009 and April 2014. INTERVENTIONS: Patients were allocated to 6 groups according to their age at the time of surgery: ≤20, 21 to 25, 26 to 30, 31 to 35, 36 to 40 and >40 years. Patient characteristics, prior history, location of endometriotic lesions, stage of disease, intraoperative findings, and surgical procedures were retrieved from a prospectively recorded database. MEASUREMENTS AND MAIN RESULTS: Patient characteristics, symptoms, location of endometriosis, and type of surgery performed were compared between groups. In total, 1560 procedures were performed. Of these, more than one-half were carried out in women between the age of 26 to 35 years and the majority were performed in women aged between 26 and 30 years. Only 2% of procedures were performed in women under the age of 20 years. The mean stage of the disease at the time of surgical diagnosis was stage II for women younger than 20 years, stage III for those in the age group of 21 to 25 years, and stage IV for those older than 26 years. The rate of diagnosis of deep colorectal nodules increased progressively from 20 to 26 years and remained stable thereafter. CONCLUSION: Our data confirm that endometriosis is a disease that probably progresses from adolescence until the adult period when symptoms (pain or infertility) become debilitating and require surgery. Our data suggest that policies relating to the prevention and early diagnosis of endometriosis should focus on women younger than 25 years.

Clubfoot Versus Positional Foot Deformities on Prenatal Ultrasound Imaging.

Clubfoot and positional foot deformities (eg, pes spinatus) may have the same aspects on prenatal ultrasound (US) imaging. Nevertheless, differentiating these entities is essential because their prognoses are different. This pictorial review illustrates the US findings of clubfoot and positional foot deformities. On the basis of clinical postnatal images, we describe a prenatal US technique that could give an accurate diagnosis. In this essay, we demonstrate that when a foot malposition is suspected, a systematic analysis with 3 rigorous planes could help differentiate positional foot deformities from malformations and define their types.

Birthweight and pregnancy outcomes in obese class II women with low weight gain: A retrospective study.

INTRODUCTION: To determine if weight gain below the institute of medicine (IOM) guidelines improves pregnancy outcomes and influences birthweight for women with class II obesity. MATERIALS AND METHODS: We retrospectively included 996 women with class II obesity with singleton gestations and delivered at term in two hospitals providing level III maternal care between January 2006 and December 2015. Women were classified into three groups: weight gain within IOM recommendations (≥5-≤9kg), low weight gain (≥0-<5kg), and weight loss (<0kg). Maternal complications and birth weight were reported in all groups. The group presenting weight gain within IOM recommendations was considered as the reference group. RESULTS: 424 women (42.5%) constituted the reference group and presented weight gain within IOM recommendations; whereas 370 (37.1%) presented low weight gain and 202 (20.3%) presented weight loss. The rate of birthweight above 4000 g was reduced in women with low weight gain (odds ratio (OR) = 0.62 [0.42-0.93]; p = 0.02) and in women with weight loss (OR = 0.58 [0.35-0.96]; p = 0.02). However, the rates of small for gestational age fetuses (SGA) < 10th percentile was increased in women with weight loss (OR = 1.63 [1.03-2.58]; p = 0.02). Maternal and neonatal complications were not significantly different between groups. CONCLUSION: While low weight gain in women with class II obesity may reduce macrosomia without excessive risk of SGA, it has no effect on maternal and neonatal complication rates.

High postoperative fertility rate following surgical management of colorectal endometriosis.

STUDY QUESTION: What are fertility outcomes in patients surgically managed for large deep endometriosis infiltrating the rectum who intend to get pregnant postoperatively? SUMMARY ANSWER: Surgical management for rectal endometriosis is followed by high pregnancy rates, with a majority of natural conceptions. WHAT IS KNOWN ALREADY: Optimal management such as surgery versus first-line ART for patients with severe deep endometriosis who desire pregnancy is not defined. STUDY DESIGN, SIZE, DURATION: The study included the patients enrolled in ENDORE randomized trial who attempted pregnancy after the surgery. From March 2011 to August 2013, we performed a two-arm randomized trial, enrolling 60 patients with deep endometriosis infiltrating the rectum up to 15 cm from the anus, measuring more than 20 mm in length, involving at least the muscular layer in depth, and up to 50% of rectal circumference. Postoperative follow-up was prolonged in 55 patients recruited at Rouen University Hospital, and varied from 50 to 79 months. No women were lost to follow-up. PARTICIPANTS/MATERIALS, SETTING, METHODS: Patients had either conservative surgery by shaving or disc excision, or radical rectal surgery by segmental resection. One gynecologist experienced in deep endometriosis surgery performed all the procedures, assisted when required by three general surgeons experienced in colorectal surgery. Institutional review board approval was obtained to extend postoperative follow-up to 10 years after the surgery. Among patients enrolled at Rouen University Hospital, women who intended to get pregnant after surgery were selected and followed up postoperatively every 6 months for 2 years, then every year. Pregnancy intention, fertility outcomes, conception mode, endometriosis recurrences and digestive and urinary outcomes were rigorously recorded. The primary outcome was postoperative pregnancy rate. Secondary outcomes were conception mode, the delay to conception from the day of surgery and the day when hormonal treatment was stopped, and delivery rate. Kaplan Meier curves were used to estimate the probability of conception after surgery. MAIN RESULTS AND THE ROLE OF CHANCE: Among the 55 patients enrolled at Rouen University Hospital, 25 had conservative and 30 had radical surgery, and their postoperative follow-up varied from 50 to 79 months. No patient was lost to follow-up. Among the 55 patients, 36 intended to get pregnant after surgery, 23 of whom had unsuccessfully attempted to conceive for more than 12 months before surgery (63%). At the end of follow-up, 29 patients achieved pregnancy (81%), and natural conception was recorded in 17 of them (59% of conceptions). As several women had more than 1 pregnancy (range: 0-3), we recorded 37 pregnancies, 24 natural conceptions (65%) and 29 deliveries (78%). The probabilities of achieving pregnancy at 12, 24, 36 and 48 months postoperatively were 33.4% (95% CI: 20.6-51.3%), 60.6% (44.8-76.8%), 77% (61.5-89.6%) and 86.8% (72.8-95.8%), respectively. Women who had been advised to attempt natural conception achieved pregnancy significantly earlier than patients referred for ART (P = 0.008). In infertile patients, the postoperative pregnancy rate was 74%, and 53% of conceptions were natural. LIMITATIONS, REASONS FOR CAUTION: The main outcomes of the original trial were related to digestive function and not to fertility. Several factors impacting fertility could not be revealed due to small sample size. The study included a high percentage of young women with an overall satisfactory prognosis for fertility, as patients' median age was 28 years. The inclusion of only large infiltrations of the rectum does not allow the extrapolation of conclusions to small nodules of <2 cm in length. Only one skilled gynecologic surgeon performed all the procedures. WIDER IMPLICATIONS OF THE FINDINGS: First-line surgery can be considered in patients with deep endometriosis infiltrating the rectum and pregnancy intention. Patients receiving advice from experienced surgeons on conception modes were more likely to conceive faster after surgery. STUDY FUNDING/COMPETING INTEREST(S): This work was supported by a grant from the clinical research program for hospitals (PHRC) in France. The authors declare no competing interests related to this study. TRIAL REGISTRATION NUMBER: The original randomized trial is registered with ClinicalTrials.gov (number NCT 01291576).

Dysregulation of the Anti-Müllerian Hormone System by Steroids in Women With Polycystic Ovary Syndrome.

Context: Anti-Müllerian hormone (AMH) and AMH type II receptor (AMHR2) are overexpressed in granulosa cells (GCs) from women with polycystic ovary syndrome (PCOS), the most common cause of female infertility. Objective: The aim of the study was to compare the regulation of the AMH/AMHR2 system by 5α-dihydrotestosterone (5α-DHT) and estradiol (E2) in GCs from control subjects and women with PCOS. Design, Setting, Patients: Experiments were performed on follicular fluids (FF) and GCs from women undergoing in vitro fertilization. Main Outcome Measures: FF steroid levels were measured by mass spectrometry, and messenger RNA (mRNA) accumulation was quantified by reverse transcription real-time polymerase chain reaction. Results: Total testosterone (T), free T, and 5α-DHT FF levels were significantly higher (P < 0.001) in women with PCOS than in controls. However, E2 and sex hormone-binding globulin concentrations were comparable between the two groups. In GCs from control women, the AMH and AMHR2 expression were not affected by 5α-DHT treatment, whereas AMH mRNA levels were upregulated by 5α-DHT in GCs from patients with PCOS (2.3-fold, P < 0.01) overexpressing the androgen receptor (1.4-fold, P < 0.05). E2 downregulated the AMH and AMHR2 expression in GCs from control women (1.4-fold, P < 0.001 and 1.8-fold, P < 0.01, respectively) but had no effect on these genes in GCs from women with PCOS. This differential effect of E2 was associated with a higher estrogen receptor 1 expression in GCs from women with PCOS (1.9-fold, P < 0.05). Conclusions: In GCs from women with PCOS, the regulation of AMH and AMHR2 expression is altered in a way that promotes the overexpression of the AMH/AMHR2 system, and could contribute to the follicular arrest observed in these patients.

Colorectal endometriosis-associated infertility: should surgery precede ART?

OBJECTIVE: To compare the impact of first-line assisted reproductive technology (ART; intracytoplasmic sperm injection [ICSI]-IVF) and first-line colorectal surgery followed by ART on fertility outcomes in women with colorectal endometriosis-associated infertility. DESIGN: Retrospective matched cohort study using propensity score (PS) matching (PSM) analysis. SETTING: University referral centers. PATIENT(S): A total of 110 women were analyzed from January 2005 to June 2014. A PSM was generated using a logistic regression model based on the age, antimüllerian hormone (AMH) serum level, and presence of adenomyosis to compare the treatment strategy. INTERVENTION(S): First-line surgery group followed by ART versus exclusive ART with in situ colorectal endometriosis. MAIN OUTCOME MEASURE(S): After PSM, pregnancy rates (PRs), live-birth rates (LBRs), and cumulative rates (CRs) were estimated. RESULT(S): After PSM, in the whole population, the total LBR and PR were 35.4% (39/110) and 49% (54/110), respectively. The specific cumulative LBR at the first ICSI-IVF cycle in the first-line surgery group compared with the first-line ART was, respectively, 32.7% versus 13.0%; at the second cycle, 58.9% versus 24.8%; and at the third cycle, 70.6% versus 54.9%. The cumulative LBRs were significantly higher for women who underwent first-line surgery followed by ART compared with first-line ART in the subset of women with good prognosis (age ≤ 35 years and AMH ≥ 2 ng/mL and no adenomyosis) and women with AMH serum level < 2 ng/mL. CONCLUSION(S): First-line surgery may be a good option for women with colorectal endometriosis-associated infertility.

Rectal Shaving Using Plasma Energy in Deep Infiltrating Endometriosis of the Rectum: Four Years of Experience.

STUDY OBJECTIVE: To evaluate postoperative complications, digestive function and fertility outcomes in patients managed by rectal shaving using plasma energy in deep infiltrating endometriosis of the rectum. DESIGN: A single-center retrospective cohort study using data recorded prospectively. DESIGN CLASSIFICATION: Canadian Task Force classification II-2. SETTINGS: Department of Gynecology and Obstetrics of Rouen University Hospital (France). PATIENTS: One hundred and ten patients treated between December 2012 and December 2016. INTERVENTIONS: Laparoscopic rectal shaving using plasma energy. MEASUREMENTS AND MAIN RESULTS: Clinical history, baseline symptoms, preoperative assessment, intraoperative findings, and postoperative outcomes were recorded prospectively. Follow-up evaluations were performed at 1 year and 3 years. Mean age of patients was 37 ± 6.4 years. Most patients had rectal nodules infiltrating either the mid or upper rectum and measuring <3 cm long. No intraoperative complications were recorded. One patient with multiple previous surgical procedures presented with a postoperative rectovaginal fistula (0.9%), and 1 patient presented with a postoperative rectouterine fistula treated exclusively with antibiotics (0.9%). Two patients (1.8%) had bladder atony necessitating ≥3 weeks of daily self-catheterization. Four patients (3.6%) had Clavien-Dindo grade I complications, 12 (10.9%) had grade II complications, 1 (0.9%) had a grade IIIa complication, 5 (4.5%) had grade IIIb complications, and 1 (0.9%) had a grade 4a complication. The vast majority of patients (n = 103 patients; 93.6%) were free of serious complications. Significant improvements in constipation and gastrointestinal quality of life were recorded at 1 year and 3 years postoperatively. Thirty-two patients attempted pregnancy after surgery (29.1%), and 17 of them conceived (53.1%). CONCLUSIONS: Rectal shaving using plasma energy allows for a low rate of postoperative complications with good digestive function and fertility outcomes and appears to be suitable in selected women with symptomatic rectal endometriosis.

Abdominal wall endometriosis following cesarean section: a study of the growth rate of parietal endometriosis implants.

BACKGROUND: The study aimed to estimate the growth rate of abdominal wall endometriosis (AWE) following cesarean section (CS), in order to potentially identify a growth model of endometriosis in vivo. METHODS: This monocentric, retrospective study included 23 patients presenting 26 nodules of post-CS AWE treated by surgical excision. Nodule surface and volume, time-lapse between surgery and AWE as well as the contraception used were noted. A comparison between nodules' features was performed depending on hormonal vs. non-hormonal contraception. RESULTS: The time-lapse between CS and AWE surgery had a mean value of 48 months. The mean surface of an AWE nodule was of 3.83 cm2, and the mean volume was of 5.32 cm3. Comparison between the main surface and volume in patients receiving hormonal vs. non-hormonal contraception was statistically non-significant. No statistically significant correlation between AWE dimension and time was revealed. In patients presenting more than one lesion, nodules appeared to grow following variable patterns. CONCLUSIONS: AWE natural history was characterized by inter- and intra-individual variability, independently of the method of contraception used.

Does preoperative antimüllerian hormone level influence postoperative pregnancy rate in women undergoing surgery for severe endometriosis?

OBJECTIVE: To compare postoperative pregnancy rates as they relate to presurgery antimüllerian hormone (AMH) level in patients with stage 3 and 4 endometriosis. DESIGN: Retrospective comparative study using data prospectively recorded in the North-West Inter-Regional Female Cohort for Patients with Endometriosis (CIRENDO) database. SETTING: University tertiary referral center. PATIENT(S): One hundred eighty patients with stage 3 and 4 endometriosis and pregnancy intention, managed from June 2010 to March 2015, were divided into two groups according to their preoperative AMH levels: group A (AMH ≥2 ng/mL) and group B (AMH <2 ng/mL). INTERVENTION(S): Surgical procedure involved ovarian endometrioma ablation by plasma energy along with resection of various localizations of the disease. Postoperative conception was either spontaneous or used assisted reproductive technology, depending on patient characteristics. MAIN OUTCOME MEASURE(S): Patient characteristics, preoperative symptoms, infertility history, intraoperative findings, and probability of pregnancy were recorded and compared between the two groups. RESULT(S): Among 180 women enrolled in the study, 134 (74.4%) were assigned to group A and 46 (25.6%) to group B. The women's ages were, respectively, 30 ± 3.8 and 32 ± 4.6 years. Pregnancy was achieved by 134 (74.4%) patients, and conception was spontaneous in 74 of them (55.2%). Pregnancy rates in groups A and B were, respectively, 74.6% (100 women) and 73.9% (34 women), while spontaneous conception represented 54% (54 women) and 58.8% (20 women). The probability of pregnancy at 12, 24, and 36 months after surgery in groups A and B was comparable, respectively, 65% (95% confidence interval [CI], 55%-75%), 77% (95% CI, 86%-68%), and 83% (95% CI, 90%-75%) versus 50% (95% CI, 69%-34%), 77% (95% CI, 90%-61%), and 83% (95% CI, 94%-68%). Supplementary analysis in women with normal (≥2 ng/mL), low (1-1.99 ng/mL), and very low (<1 ng/mL) AMH level showed an inverse relationship between AMH level, age, and antecedents of miscarriage; however, postoperative pregnancy rates were comparable among the three groups at 12 and 24 months, respectively, 59.5% (95% CI, 49.3%-70%) and 77.4% (95% CI, 68%-85.4%); 57.1% (95% CI, 34%-83%) and 78.6% (95% CI, 55.2%-94.8%); and 46.7% (95% CI, 25.6%-73.7%) and 73.3% (95% CI, 50.4%-91.7%). CONCLUSION(S): The probability of postoperative pregnancy was comparable between women with low and normal AMH level who were managed for stage 3 and 4 endometriosis and who were a mean age of 30 years. However, the small sample size might have been unable to detect differences in pregnancy and live-birth rates between the two groups. As the majority of pregnancies were spontaneous, our results suggest that surgical management may be offered to young patients with severe endometriosis and reduced ovarian reserve with good fertility outcomes.

Prior colorectal surgery for endometriosis-associated infertility improves ICSI-IVF outcomes: results from two expert centres.

OBJECTIVE(S): To assess fertility outcomes after ICSI-IVF in infertile women having undergone prior complete surgical removal of colorectal endometriosis. STUDY DESIGN: Prospective longitudinal cohort study in two referral French centres including 60 infertile women who underwent ICSI-IVF after complete surgical removal of colorectal endometriosis, from January 2005 to May 2014. Women underwent either conservative colorectal surgery (i.e., rectal shaving or full thickness disc excision, n=18) or segmental colorectal resection (n=42). Clinical pregnancies were defined by the presence of a gestational sac on vaginal ultrasound examination from the fifth week. The overall pregnancy rate was calculated. The Kaplan-Meier method was used to estimate the cumulative pregnancy rate (CPR). Comparisons of CPR were made using the log-rank test to detect determinant factors. RESULTS: The median number of ICSI-IVF cycles per patient was one (range: 1-4). Of the 60 women, 36 became pregnant (i.e., overall pregnancy rate=60%). The CPR was 41.7% after one ICSI-IVF cycle, 65% after two ICSI-IVF cycles and 78.1% after three ICSI-IVF cycles. A decreased CPR was observed for women who required segmental colorectal resection compared to those who underwent rectal shaving or full thickness disc excision (p=0.04). A trend for a decreased CPR was observed for women who received a first ICSI-IVF cycle more than 18 months following surgery (p=0.07). Among the nine women with prior ICSI-IVF failure, five (55.5%) became pregnant after surgery. CONCLUSION(S): Colorectal surgery for endometriosis completed by ICSI-IVF is a good option for women with proven infertility, even if prior ICSI-IVF had failed.