Use of the EFI score in endometriosis-associated infertility: A cost-effectiveness study.

BACKGROUND: The management of endometriosis-related infertility is still under debate. The Endometriosis Fertility Index (EFI) score is performant to predict the occurrence of a spontaneous pregnancy following surgery, but was not evaluated in a cost-effectiveness perspective. Our objective was to quantify fertility outcomes, and costs of different care pathways for endometriosis-associated infertility after primary surgery, with a stratification on the EFI score. STUDY DESIGN: We conducted a cost-effectiveness analysis based on a decision-tree model in a Tertiary-care university hospital. Extracted form a prospectively maintained database, 608 patients with endometriosis-associated infertility, who underwent laparoscopic treatment with an evaluation of the EFI score, were discriminated between different strategies: natural conception, immediate IVF-ICSI, delayed IVF-ICSI. The pregnancy rate and the live birth rate were the effectiveness outcomes. We considered direct and indirect costs in each strategies. The analysis was stratified according to the EFI score. RESULTS: After surgery, 163 women with immediate IVF-ICSI (strategy I) were compared with 445 women who had natural conception attempts during a year (strategy II). After a year failure of natural conception attempts, 133 women continuing natural conception attempts (strategy III) were compared with 168 women who had delayed IVF-ICSI (strategy IV). The respective PR and LBR were 62.6 % and 52.1 % for strategy I, and 32.4 % and 23.8 % for strategy II. Compared to strategy II, strategy I was more costly and more effective (Incremental Cost Effectiveness Ratio (ICER): 31,469 €/pregnancy and 33,568 €/live birth)). No added benefit was observed for patients in strategy I with an EFI score [0-3] after two IVF-ICSI cycles. Strategy III was strongly dominant versus strategy IV for patients with an EFI score [9-10]. Compared to strategy III, strategy VI was more costly and more effective (ICER: 79,674 €/pregnancy, 53,188 €/pregnancy and 27,748 €/pregnancy respectively for patients with an EFI score [7-8], [4-6] and [0-3]). CONCLUSION: Immediate IVF-ICSI after surgery is effective but associated with substantial costs for the healthcare system. Taking into account healthcare costs, the EFI is a useful score for helping a couple decide between different care pathways -natural conception, immediate or delayed IVF-ICSI- after surgery for endometriosis-associated infertility.

Human epidemiological evidence about the associations between exposure to organochlorine chemicals and endometriosis: Systematic review and meta-analysis.

BACKGROUND: Endometriosis is a gynaecological disease characterized by the presence of ectopic endometrial tissue that affects women during their reproductive years, having a strong impact on their lives, fertility and healthcare costs. The aetiology remains largely unknown, but current evidence suggests that it is multi-causal and oestrogen-dependent. Many epidemiologic studies have explored associations between organochlorine chemicals (OCCs) and endometriosis, but the findings are inconsistent. OBJECTIVES: A systematic review (SR) and meta-analysis were conducted to gather and synthesize all the available evidence from human epidemiological studies about the associations between OCCs and endometriosis. DATA SOURCES: The searches were conducted in PubMed and Web of Science in June 2016 with a final follow-up in August 2018. STUDY ELIGIBILITY CRITERIA: Only human epidemiological studies were considered, independent of participant age, body mass index or life-stage. Studies reporting individual measures of exposure to OCCs were included, considering but not limited to polychlorinated dibenzodioxins and dibenzofurans (PCDD/Fs), polychlorinated biphenyls (PCBs), or organochlorine pesticides (OCPs). The primary health outcome was presence of endometriosis, including all sub-types. Eligibility criteria excluded articles not written in English, conference papers, reviews and studies with overlapping information. STUDY APPRAISAL AND SYNTHESIS METHODS: A SR protocol pre-registered at PROSPERO was applied in duplicate to gather and extract all eligible original papers from PUBMED and Web of Science databases. Odds ratios were pooled using the inverse variance method for random effects meta-analysis for each group of OCCs. Risk of bias was assessed using the National Toxicology Program/Office of Health Assessment and Translation (NTP/OHAT) Risk of Bias Rating Tool for Human and Animal Studies adapted to the review question. The confidence in the body of evidence and related level of evidence was measured by using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) based NTP/OHAT framework. The results were structured and presented in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS: Of the 51 studies retained for the full-text screening, 17 provided effect sizes and metrics sufficient for pooling estimates through meta-analysis. The overall odds ratios and 95% confidence intervals were 1.65 (1.14; 2.39) for dioxins (n = 10), 1.70 (1.20; 2.39) for PCBs (n = 9), and 1.23 (1.13; 1.36) for OCPs (n = 5). Despite being statistically significant, these estimates should be considered with caution given the notable heterogeneity and small estimated effect size. Misclassification of exposure, due to varying laboratory detection rate capabilities, and disease status, due to varying definitions of endometriosis, were identified as major sources of uncertainty. LIMITATIONS, CONCLUSIONS, AND IMPLICATIONS OF KEY FINDINGS: The level of evidence was considered to be "moderate" with "serious" risk of bias according the NTP/OHAT criteria, supporting the need for further well-designed epidemiological research to fill lingering data gaps. Given the complexity of endometriosis and lack of known biomarkers suitable for population-based research, carefully designed observational studies play an important role in better understanding the aetiology of endometriosis, as will evolving mixture modeling approaches capable of handling various environmental chemical exposures. Attention to critical windows of exposure will shed further light on the possible developmental origin of endometriosis. Considering the high economic and societal cost associated with endometriosis, further research on this field is urged. SYSTEMATIC REVIEW REGISTRATION NUMBER: CRD42018080956.

Impact of hospital and surgeon case volume on morbidity in colorectal endometriosis management: a plea to define criteria for expert centers.

National and international guidelines recommend referring patients with severe forms of endometriosis to expert centers. However, there is a lack of clear criteria to define an expert center. We examined the roles of surgeon and hospital procedure volumes as determinants of morbidity in deep infiltrating endometriosis of the rectum and sigmoid colon (DIERS). METHODS: We conducted a French retrospective multicenter study of hospital facilities performing colorectal surgery for DIERS in 2015. The primary end point was to analyze the relation between case volume and the incidence of complications. We estimated the optimal cut-off (OCO) determined by a minimal p-value approach. RESULTS: The study included 56 hospital facilities and collected data of 1135 cases of surgical management of colorectal endometriosis. The mean and median number of procedures per year and per surgeon were 9.17 and 5.58, respectively. The overall rate of grade III-V complication was 7.6% (82/1135). One grade V complication occurred. The rates of rectovaginal fistula, anastomotic leakage, pelvic abscess, and ureteral fistula were: 2.7% (31/1135), 0.79% (9/1135), 3.4% (39/1135), and 0.70% (8/1135), respectively. An OCO of 20 procedures per center and per year (p < 0.001) was defined. The OCO per surgeon and per year varied between seven (p = 0.007) and 13 procedures (p = 0.03). In a multivariate analysis, we found that only the volume of activity was independently correlated to complication outcomes (p = 0.0013). CONCLUSION: Our results contribute to providing objective morbidity data to determine criteria for defining expert centers for colorectal surgery for endometriosis.

[Imaging in the initial and preoperative assessment of endometriosis]. / Apport de l'imagerie dans le bilan initial et préopératoire de l'endométriose.

The diagnosis of pelvic endometriosis is based on the combination of clinical examination, endovaginal ultrasonography and pelvic MRI. Ultrasonography displays a moderate sensitivity and a high specificity. Pelvien MRI displays a better sensitivity and lower specificity.

Hormonal prevention of breast cancer.

Breast cancer prevention can be provided by using SERMs or aromatase inhibitors depending on the ovarian status, with a global risk reduction of 50 to 60%. Prophylactic annexectomy offered to reduce ovarian risk in BRCA mutation carriers also lowers breast cancer risk by 50%. Main side effects include deep vein thrombosis for SERMs, hot flushes and joint pain (although less frequently than initially suspected) with aromatase inhibitors. Other strategies based on progesterone, insulin or prolactin signaling modulation may be offered in the future. Criteria for candidate selection remain to be established.

Genital prolapse repair using porcine skin implant and bilateral sacrospinous fixation: midterm functional outcome and quality-of-life assessment.

OBJECTIVES: To evaluate the midterm anatomic and functional outcome of genital prolapse repair by the vaginal route using a porcine skin implant (Pelvicol) and bilateral sacrospinous fixation. METHODS: From May 2001 to June 2006, 101 patients with Stage III-IV genital prolapse were treated using a porcine skin collagen implant and bilateral sacrospinous fixation. The functional results were evaluated using the Pelvic Floor Distress Inventory short form, Pelvic Organ Prolapse Distress Inventory-6, Colorectal Anal Distress Inventory-8, Urogenital Distress Inventory-6, Pelvic Floor Impact Questionnaire-7 (including Urinary Impact Questionnaire-7, Pelvic Organ Prolapse Impact Questionnaire-7, and Colo-Rectal-Anal Impact Questionnaire-7), and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire. RESULTS: Of the 101 patients, 89 (88%) completed all the questionnaires. The mean follow-up was 38 +/- 18 months. An improvement was noted in the Pelvic Organ Prolapse Distress Inventory-6 (P < .0001), Urogenital Distress Inventory-6 (P = .001), and Pelvic Floor Distress Inventory scores (P < .0001) but not in the Colorectal Anal Distress Inventory-8 scores. An improvement was noted in the Urinary Impact Questionnaire-7 (P < .0001), Pelvic Organ Prolapse Impact Questionnaire-7 (P < .0001), and Pelvic Floor Impact Questionnaire Short Form 7 (p < 0.0001) scores but not in the Colo-Rectal-Anal Impact Questionnaire-7 scores. The quartile distribution showed that women with a preoperative Pelvic Floor Distress Inventory-short form score >133 had a 45% chance of postoperative improvement and those with a preoperative Pelvic Floor Impact Questionnaire Short Form 7 score >195 had an 81% chance of postoperative improvement. Using multivariate regression analysis, the preoperative Pelvic Floor Distress Inventory score was negatively predictive of satisfaction (t = -2.03, P = .05) and the preoperative Pelvic Floor Impact Questionnaire Short Form 7 score was positively predictive of satisfaction (t = 2.40, P = .02). No differences in the pre- and postoperative Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire scores were noted. CONCLUSIONS: The results of our study have shown that biologic implantation and bilateral sacrospinous fixation are effective in high-grade genital prolapse repair. Validated questionnaires are potentially useful tools to predict the postoperative outcome.

Sonography and MR imaging for the assessment of deep pelvic endometriosis.

Deep pelvic endometriosis may involve the uterosacral ligaments, the pouch of Douglas, the vagina, the rectum, and occasionally the bladder. Assessment by physical examination is difficult, and imaging techniques are needed to evaluate the location and extent of endometriosis. In this review, we describe transvaginal and rectal endoscopic sonographic and magnetic resonance imaging features suggestive of deep pelvic endometriosis and their diagnostic performance.

Transvaginal sonography and rectal endoscopic sonography for the assessment of pelvic endometriosis: a preliminary comparison.

BACKGROUND: Endometriosis and possible rectal involvement are difficult to assess by physical examination. Previous studies have shown the diagnostic value of magnetic resonance imaging and rectal endoscopic sonography (RES) in this setting, but not that of transvaginal sonography (TVS). The aims of this study were to compare the accuracy of TVS and RES for the diagnosis of pelvic endometriosis, and to compare the results with histological findings. PATIENTS AND METHODS: In a prospective study, 30 consecutive patients referred with clinical signs of endometriosis underwent TVS and RES; the images were interpreted blindly with regard to physical findings. RESULTS: Endometriosis was confirmed histologically in 28 (93%) of the 30 patients. Endometriomas were also present in 67% of cases. For the diagnosis of uterosacral endometriosis, the sensitivity, specificity, and positive and negative predictive values of TVS and RES were 75 and 75%, 83 and 67, 95 and 90%, and 45 and 40% respectively. For the diagnosis of rectosigmoid endometriosis, the sensitivity, specificity, and positive and negative predictive values of TVS and RES were 95 and 82%, 100 and 88%, 100 and 95%, and 89 and 64% respectively. CONCLUSION: Despite the large proportion of our patients who had intestinal endometriosis, representing a possible source of bias, our results suggest that TVS is as efficient as RES for detecting posterior pelvic endometriosis and should therefore be used as the first-line examination.