Antimüllerian hormone levels and IVF outcomes in polycystic ovary syndrome women: a scoping review.

Antimüllerian hormone (AMH) is a homodimeric glycoprotein secreted by granulosa cells from primary to large antral follicles, and it plays an important role in the regulation of early follicle growth. It is considered a reliable marker of ovarian reserve and a predictor of ovarian response to controlled stimulation. Polycystic ovary syndrome (PCOS) is an endocrine condition that affects women of reproductive age worldwide, and it is associated with high levels of AMH. PCOS patients may have worse maturation and fertilization rates compared to normo-ovulatory women. Some studies have demonstrated a positive correlation between AMH levels and qualitative aspects of assisted reproduction treatment; but it is not clear whether high levels of both serum and follicular fluid AMH in PCOS patients correlate with in vitro fertilization outcomes. We ran this scoping review of the literature to address this specific question. We comprehensively searched the databases PubMed and Cochrane Library until January 2023. We found that higher AMH levels are associated with higher oocyte yield, but PCOS patients tend to have fewer mature oocytes and impaired embryo quality and implantation rates. Pregnancy rates, however, are not affected by AMH levels or laboratorial outcomes. We also found that higher AMH levels are associated with worse PCOS features.

Measurement of serum and peritoneal levels of amyloid protein A and their importance in the diagnosis of pelvic endometriosis.

OBJECTIVE: To evaluate serum and peritoneal concentrations of amyloid protein A in women with endometriosis and to compare them with those of women without endometriosis. STUDY DESIGN: A prospective study evaluated 76 women suspected of having pelvic endometriosis. Fifty-seven women (group A) were confirmed by videolaparoscopy and had their serum and peritoneal amyloid A concentrations measured by ELISA. The average levels from group A were compared to those obtained in group B. Group B was composed of 13 women without endometriosis, submitted to elective laparoscopy for tubal ligation. RESULTS: Peritoneal amyloid A concentrations in group A (310.3 +/- 97.8 ng/mL) were higher than those of group B (53.4 +/- 58.2 ng/mL); p = 0.0. However, serum concentrations in groups A (14.01 +/- 32.3 ng/mL) and B (9.5 +/- 15.9 ng/mL) did not differ significantly; p = 0.35. CONCLUSION: The peritoneal amyloid A protein concentration in pelvic endometriosis was higher when compared to normal controls, corroborating the inflammatory nature of the disease. This finding suggests that the procedure of evaluating the peritoneal amyloid A concentration in endometriosis merits further investigation.

Patients with endometriosis of the rectosigmoid have a higher percentage of natural killer cells in peripheral blood.

STUDY OBJECTIVE: To estimate the concentration of natural killer (NK) cells in the peripheral blood in patients with and without endometriosis. DESIGN: Case-control study (Canadian Task Force classification II-2). SETTING: Tertiary referral hospital. PATIENTS: One hundred fifty-five patients who had undergone videolaparoscopy were divided into 2 groups: those with endometriosis (n = 100) and those without endometriosis (n = 55). INTERVENTIONS: The percentage of NK cells relative to peripheral lymphocytes was quantified at flow cytometry in 155 patients who had undergone laparoscopy. In addition to verifying the presence of endometriosis, stage of disease and the sites affected were also evaluated. MEASUREMENTS AND MAIN RESULTS: The mean (SD) percentage of NK cells was higher (15.3% [9.8%]) in patients with endometriosis than in the group without the disease (10.6% [5.8%]) (p < .001). The percentage of NK cells was highest (19.8 [10.3%]) in patients with advanced stages of endometriosis and in those in whom the rectosigmoid colon was affected. In a statistical model of probability, the association of this marker (NK cells ≥11%) with the presence of symptoms such as pain and intestinal bleeding during menstruation and the absence of previous pregnancy yielded a 78% likelihood of the rectosigmoid colon being affected. CONCLUSION: Compared with patients without endometriosis, those with endometriosis demonstrate a higher concentration of peripheral NK cells. The percentage of NK cells is greater, primarily in patients with advanced stages of endometriosis involving the rectosigmoid colon. Therefore, it may serve as a diagnostic marker for this type of severe endometriosis, in particular if considered in conjunction with the symptoms.

Quality of life after segmental resection of the rectosigmoid by laparoscopy in patients with deep infiltrating endometriosis with bowel involvement.

STUDY OBJECTIVE: To estimate the quality of life of patients undergoing laparoscopic resection of a segment of the rectosigmoid for the treatment of deep infiltrating endometriosis with bowel involvement. DESIGN: Prospective application of the SF-36 Health Status Questionnaire to 151 women before and 1 year after surgical intervention (Canadian Task Force Design Classification II). SETTING: Department of Obstetrics and Gynecology, University of São Paulo Medical School, and Samaritano Hospital, São Paulo, Brazil. PATIENTS: A total of 151 women (mean age 34.05 ± 5.65 years) with deep infiltrating endometriosis underwent resection of a segment of the rectosigmoid by laparoscopy between 2002 to 2009. INTERVENTIONS: All the patients had historical data collected and underwent clinical examination and transvaginal ultrasonography with prior bowel preparation for resection of a segment of the rectosigmoid by laparoscopy indicated for patients with symptoms (pelvic pain) with 1 or more lesions of more than 3 cm in length or multifocal lesions. MEASUREMENTS AND MAIN RESULTS: Wilcoxon signed rank test verified differences between the degrees of the symptoms and the SF-36 scores before and 1 year after laparoscopic treatment. There was a significant improvement (p < .001) in all pain-related symptoms, as well as a significant increase (p < .001) in scores in all the SF-36 domains and in the sum of the components comprising both physical and mental health. CONCLUSION: Laparoscopic segmental resection of the rectosigmoid fulfills its essential objective of treating endometriosis with bowel involvement and improving patients' QoL to a significant extent.

Epidemiological and clinical aspects of pelvic endometriosis­a case series.

OBJECTIVE: To describe clinical and epidemiological aspects of patients with pelvic endometriosis who underwent laparoscopy at our service. METHODS: Retrospective study of 892 post-laparoscopy patients with histologically confirmed diagnosis of endometriosis. RESULTS: Mean age was 33.2 ± 6.3 years, and 78.7% of patients were Caucasian. We found that 76.9% of women in the sample had a higher education. Most (56.5%) patients were nulliparous, and 62.2% reported dysmenorrhea as the chief complaint. Chronic pelvic pain was the most prevalent symptom, followed by deep dyspareunia, reported by 56.8% and 54.7% of patients respectively. Infertility was reported by 39.8% of the 892 patients in the sample. CONCLUSION: Endometriosis is most often diagnosed in the fourth decade of life. Patients with this condition present with multiple complaints, and must always undergo thorough questioning to properly guide diagnosis and monitor treatment results.

Transvaginal ultrasonography with bowel preparation is able to predict the number of lesions and rectosigmoid layers affected in cases of deep endometriosis, defining surgical strategy.

BACKGROUND: Successful surgical treatment of deep bowel endometriosis depends on obtaining detailed information about the lesions, prior to the procedure. The objective of this study was to determine the capability of transvaginal ultrasonography with bowel preparation (TVUS-BP) to predict the presence of one or more rectosigmoid nodules and the deepest bowel layer affected by the disease. METHODS: A prospective study of 194 patients with clinical and TVUS-BP suspected deep endometriosis submitted to videolaparoscopy. Image data were compared with surgical and histological results. RESULTS: With respect to bowel nodule detection and presence of at least two rectosigmoid lesions, TVUS-BP had a sensitivity of 97 and 81%, specificity 100 and 99%, positive predictive value (PPV) 100 and 93% and negative predictive value (NPV) 98 and 96%, respectively. Regarding diagnosis of infiltration of the submucosal/mucosal layer, TVUS-BP had a sensitivity of 83%, specificity 94%, PPV 77%, NPV 96%. CONCLUSIONS: These findings show that TVUS-BP is an adequate exam for evaluating the presence of one or more rectosigmoid nodules and the deepest layer affected in deep infiltrating bowel endometriosis, confirming the importance of this technique for defining the most appropriate surgical strategy to be implemented.

Endometriosis at several sites, cyclic bowel symptoms, and the likelihood of the appendix being affected.

In patients with endometriosis of the appendix, other sites are use to be affected by the disease, mainly bladder, rectosigmoid and retrocervical endometriosis. When these characteristics are present or if patients have more than three sites affected by endometriosis, the surgeon should evaluate the appendix carefully.

Interleukin-12 but not interleukin-18 is associated with severe endometriosis.

OBJECTIVE: To evaluate interleukin (IL)-12 and IL-18 levels in the serum and peritoneal fluid of women with and without endometriosis. DESIGN: Cross-sectional survey. SETTING: University hospital. PATIENTS: Interleukin-12 and IL-18 levels were compared in 105 patients submitted to laparoscopy because of symptoms suggestive of endometriosis (pain and/or infertility). The disease was confirmed in 72 patients (study group), while in 33 patients findings were not compatible with endometriosis (control group). INTEVENTION(S): Blood sample and peritoneal fluid were obtained from patients during videolaparoscopy. MAIN OUTCOME MEASURE(S): The levels of IL-12 and IL-18 in peripheral blood and peritoneal fluid were determined and compared with the stage and site of the disease and histologic classification. RESULT(S): IL-12 levels measured in peritoneal fluid were higher in patients with endometriosis compared with the control group. A significant increase in IL-12 levels was found when the more advanced stages of the disease were compared with the initial stages. No statistically significant differences were found in IL-18 levels, either in serum or in peritoneal fluid samples. CONCLUSION(S): Patients with severe endometriosis have higher IL-12 levels irrespective of IL-18 levels, suggesting that in this disease an alternative pathway is involved in induction of the Th1 immune response.

Endometriosis of the ureter and bladder are not associated diseases.

OBJECTIVE: To verify whether bladder and ureter endometriosis had the same clinical features and disease behavior. DESIGN: Case-control study. SETTING: Multidisciplinary group in Sao Paulo, Brazil. PATIENT(S): A total of 690 patients were submitted to laparoscopy with histologically diagnosis of endometriosis between July 1999 and December 2006. Twelve of these patients had lesions affecting the ureter and 26 had lesions affecting the bladder. A control group consisted of 652 patients in whom endometriosis was not affecting either the ureter or the bladder. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Clinical and surgical features of patients with ureteral or bladder endometriosis. RESULT(S): No patients with ureteral endometriosis had lesions affecting the bladder. Compared with the control group, patients with ureteral endometriosis had more advanced disease (Stages III and IV) according to the American Society of Reproductive Medicine (ASRM) staging classification (100% vs. 65.5%); they also had more retrocervical (83.3% vs. 21.6%) and rectum-sigmoid lesions (91.7% vs. 17.9%). Compared with the control group, more patients with bladder endometriosis had cyclic dysuria and/or hematuria (34.6% vs. 9.8%), more advanced stages of the disease (88.4% vs. 65.5%), and an association with endometriosis of the rectum-sigmoid (65.3% vs. 17.9%). CONCLUSION(S): Ureter endometriosis is not associated with the bladder disease; however, it is associated with advanced ASRM stages and with retrocervical and rectum-sigmoid lesions.

Endometriosis lesions that compromise the rectum deeper than the inner muscularis layer have more than 40% of the circumference of the rectum affected by the disease.

STUDY OBJECTIVE: To estimate the relationship between the depth of lesions of rectal endometriosis and the percentage of the circumference of the bowel segment affected by the disease. DESIGN: A prospective pathologic analysis of 45 surgical specimens of bowel endometriosis obtained by laparoscopic segmental resection of the rectosigmoid (Canadian Task Force classification II-1). SETTING: Tertiary referral hospital. PATIENTS: forty-five patients were submitted to a segmental resection of the rectum due to endometriosis between July 2004 and September 2006. INTERVENTIONS: Morphometric aspects of endometriotic lesions were analyzed, such as size and thickness of the lesion, deepest layer of bowel affected by lesion, and percentage of circumference of bowel affected by endometriosis. MEASUREMENTS AND MAIN RESULTS: Results showed that in lesions that reached the submucous layer of the bowel, the circumference affected was 31.6% greater than in lesions that reached only the outer muscular layer, whereas in lesions that reached the mucous layer, the circumference affected was 52.5% greater than in those that reached the outer muscular layer of the bowel. In addition, 89.3% of lesions with an affected circumference greater than 40% were those affecting the submucous or mucous layers of the bowel. These results suggest that when a lesion reaches these 2 deepest layers of the rectosigmoid, risk increases that the circumference affected will be greater than 40% (relative risk = 1.5; 95% CI: 1.0-2.3; p = .03). CONCLUSION: In endometriotic lesions affecting the rectosigmoid beyond the inner muscular layer of the bowel wall, more than 40% of the circumference of the rectosigmoid is affected by the disease, confirming the recommendation of segmental resection of the bowel for this form of the disease.

Comparison between clinical examination, transvaginal sonography and magnetic resonance imaging for the diagnosis of deep endometriosis.

BACKGROUND: Deeply infiltrating endometriosis affecting the retrocervical region and the rectosigmoid generally requires surgical treatment. Clinical examination, transvaginal ultrasonography (TVUS) and pelvic magnetic resonance imaging (MRI) are useful in the preoperative diagnosis of the involvement of these sites. The objective of this study was to evaluate the capacity of digital vaginal examination, TVUS and MRI to diagnose rectosigmoid and retrocervical involvement. METHODS: A total of 104 patients with clinically suspected endometriosis were submitted to clinical examination, pelvic MRI and TVUS until 3 months prior to videolaparoscopy and the findings of these methods were matched with histopathological confirmation of endometriosis. RESULTS: Endometriosis was histologically confirmed in 98 of 104 (94.2%) patients. With respect to the rectosigmoid and retrocervical sites, respectively, digital vaginal examination had a sensitivity of 72 and 68%, specificity of 54 and 46%, positive predictive value (PPV) of 63 and 45%, negative predictive value (NPV) of 64 and 69% and accuracy of 63 and 55%. For TVUS, sensitivity was 98 and 95%, specificity 100 and 98%, PPV 100 and 98%, NPV 98 and 97% and accuracy 99 and 97%. MRI had a sensitivity of 83 and 76%, specificity of 98 and 68%, PPV of 98 and 61%, NPV of 85 and 81% and accuracy of 90 and 71%. CONCLUSIONS: TVUS had better sensitivity, specificity, PPV, NPV and accuracy in cases of deep retrocervical and rectosigmoid endometriosis when compared with MRI and digital vaginal examination, confirming that it is an important preoperative examination for the definition of surgical strategies.

Deeply infiltrating endometriosis affecting the rectum and lymph nodes.

OBJECTIVE: To analyze morphologic aspects of bowel endometriosis. DESIGN: Prospective study of 35 consecutive cases of bowel endometriosis. SETTING: Multidisciplinary group practice and teaching hospital. PATIENT(S): Thirty-five patients with bowel endometriosis were assessed between September 2003 and June 2005. INTERVENTION(S): Histologic analysis of 35 tissue samples removed at laparoscopic rectosigmoidectomy. MAIN OUTCOME MEASURE(S): We performed an evaluation of lesion size, number of lesions present in the bowel, intestinal wall layers affected by the endometriotic lesion, circumference of the intestinal loop affected by the endometriotic lesion, and presence of lymph nodes with foci of endometriosis. RESULT(S): Analysis of the surgical samples revealed lymph nodes in the pericolic adipose tissue of 19 (54%), cases and in 5 of these cases (26.3%), endometriosis had affected the lymph nodes. When the thickness of the endometriotic lesion reached 1.75 cm, lymph nodes of all patients were affected, and all patients in whom more than 80% of the circumference of the intestinal loop was affected by endometriosis presented with positive lymph nodes. CONCLUSION(S): This study raises doubts about whether this form of the disease can still be considered a clinically benign disease.

Bowel endometriosis and schistosomiasis: a rare but possible association.

OBJECTIVE: To report the case of a patient submitted to laparoscopic bowel resection in whom histology revealed endometriosis and schistosomiasis. DESIGN: Case report. SETTING: Multidisciplinary group practice and teaching hospital. PATIENT(S): A 31-year-old patient with pelvic pain. INTERVENTION(S): Laparoscopic bowel resection. MAIN OUTCOME MEASURE(S): Laparoscopic treatment of endometriosis affecting the sigmoid. RESULT(S): Histology performed on tissue removed at surgery revealed epithelioid granulomas with birefringent and partially calcified eggs characteristic of Schistosoma mansoni within an endometriotic lesion affecting the entire width of the sigmoid. CONCLUSION(S): Endometriosis and schistosomiasis may be present simultaneously in patients with bowel symptoms and pelvic pain.