To the Editor:
We read with great interest the manuscript by Fanfani et al., which reports their experience with laparoscopic treatment of bowel-infiltrating endometriosis (1). The authors analyzed their patients in regards to operative long-term complications, pain relief and recurrence rate, and suggest a surgical management algorithm. However, women with bowel endometriosis, besides having gastrointestinal symptoms and pain, frequently suffer from infertility.
We mostly agree with the proposed treatment algorithm, but believe some data regarding fertility after surgery should be pointed out and considered.
Fanfani et al. reported a 27.3% pregnancy rate in women subjected to discoid resection suffering from infertility (1). These data appear below the 44% previously reported by Mohr et al. in 9 patients subjected to discoid resection (2). By contrast, no information regarding the pregnancy rate is given for the control group undergoing segmental bowel resection (2).
It should be noted, that segmental resection by laparotomy yields fertility rates between 39.4% and 50% (3,4). Laparoscopic colorectal resection for endometriosis has been shown to be feasible (5,6), and recent findings have convincingly shown that, in this setting of patients, laparoscopy yields better results when compared to traditional laparotomy (7). Ferrero et al. reported fertility rates as high as 43% in 21 infertile women after bowel resection, and Darai et al. reported a 45.5% pregnancy rate among 22 women wishing to conceive after laparoscopic segmental colorectal resection (7,8) (Table 1).
The mechanism by which endometriosis impairs fertility has not yet been clearly defined and probably ges beyond a simple mechanical explanation. Infertility could be explained by functional alterations of the peritoneal environment affecting gamete, embryo or fallopian tube function, in addition to the important pelvic anatomical abnormalities (9). Remorgida et al. reported that endometriotic tissue remains in over 40% of women subjected to full-thickness disc resection. These authors hypothesized that endometriotic tissue can spread laterally from the primary nodule following the enteric nervous system, thus explaining the low rate of radical discoid resection (10). The persistence of microscopic endometriotic foci could have an effect on fertility.
Until the pathophysiological relationship between endometriosis and infertility is fully understood, surgeons will be required to balance their “conservative attitude” with surgical radicality. Currently, we believe that it would be of great interest to have the fertility results achieved in the segmental resection group in this important study, in order to better tailor the proposed treatment algorithm and apply it to women with infertility.
Marco Calcagno, M.D.
Filippo Bellati, M.D.
Maria Pastore, M.D.
Francesco Plotti, M.D.
Innocenza Palaia, M.D.
Pierluigi Benedetti Panici, M.D.
Department of Obstetrics and Gynecology
University “La Sapienza”
1. Fanfani F, Fagotti A, Gagliardi ML, Ruffo G, Ceccaroni M, Scambia G, Minelli L. Discoid or segmental rectosigmoid resection for deep infiltrating endometriosis: a case-control study. Fertil Steril 2009; doi:10.1016/j.fertnstert.2009.03.066
2. Mohr C, Nezhat FR, Nezhat CH, Seidman DS, Nezhat CR. Fertility consideration in laparoscopic treatment of infiltrative bowel endometriosis. J Soc Laparosc Surg 2005;9:16–24.
3. Coronado C, Franklin RR, Lotze EC, Bailey HR, Valdes CT. Surgical treatment of symptomatic colorectal endometriosis. Fertil Steril 1990;53:411–6.
4. Bailey HR, Ott MT, Hartendorp P. Aggressive surgical management for advanced colorectal endometriosis. Dis Colon Rectum 1994;37:747–53.
5. Possover M, Diebolder H, Plaul K, Schneider A. Laparoscopically assisted vaginal resection of rectovaginal endometriosis. Obstet Gynecol 2000;96:304 –7.
6. Redwine DB, Wright JT. Laparoscopic treatment of complete obliteration of the cul-de-sac associated with endometriosis: long-term follow- up of en bloc resection. Fertil Steril 2001;76:358–65.
7. Ferrero S, Anserini P, Abbamonte LH, Ragni N, Camerini G, Remorgida V. Fertility after bowel resection for endometriosis. Fertil Steril. 2009;92(1):41-6.
8. Darai E, Marpeau O, Thomassin I, Dubernard G, Barranger E, Bazot M. Fertility after laparoscopic colorectal resection for endometriosis: preliminary results. Fertil Steril 2005;84:945–50.
9. Witz CA, Burns WN. Endometriosis and infertility: is there a cause and effect relationship? Gynecol Obstet Invest 2002;53 Suppl 1:2–11.
10. Remorgida V, Ragni N, Ferrero S, Anserini P, Torelli P, Fulcheri E. How complete is full thickness disc resection of bowel endometriotic lesions? A prospective surgical and histological study. Hum Reprod 2005;20:2317–20.
Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2009.10.057
The Authors Respond:
We appreciate the letter by Calcagno et al. regarding indications for surgery for deep infiltrating endometriosis (DIE) and posed questions about our study (1).
We proposed a management algorithm for DIE (1) underlining the opportunity to treat only patients with symptoms or asymptomatic patients with severe bowel stenosis. Both discoid and segmental rectosigmoid resection were found to be safe and feasible, with superimposable clinical outcomes (1). In this study, we reported a 27.3% spontaneous pregnancy rate in women referred preoperatively for infertility who underwent discoid resection.
Calcagno et al. suggest that this result appears lower than those reported by other authors on discoid (2) and/or segmental rectosigmoid resections (3). However, in these studies (2,3) the fertility data are not homogeneous and the number of cases is very low. In particular, the reported pregnancy rate is not separated into spontaneous and assisted pregnancy, and there are no data regarding preoperative infertility. It is impossible to assume that in all study populations infertility is due only to the presence of endometriosis, thus suggesting that only spontaneous pregnancy after radical endometriosis ablation can be considered a result of endometriosis-related infertility. Nevertheless, we have previously reported our series of laparoscopic colorectal segmental resection for DIE, showing a pregnancy rate comparable with other studies (41.6%), but with the vast majority (80%) assisted by a reproductive technique (4). In the segmental resection group (controls) of the present study (1), the pregnancy rate is almost the same, with a global pregnancy rate of 42%, of which 75% used an assisted reproductive technique. These data confirm that our results in terms of post-operative pregnancy rate are similar to those reported in the literature.
In addition, Calcagno et al. suggest that desire for fertility should be taken into account in the surgical treatment algorithm of DIE patients, and that the persistence of microscopic endometriosis foci after discoid resection showed by Remorgida et al. (5) could have a negative effect on fertility. Stepniewska et al. (6) showed that the presence of bowel infiltration by endometriosis negatively influences the reproductive outcome in women with endometriosis-associated infertility, concluding that the complete removal of endometriosis seems to offer better results in terms of post-operative fertility with respect to patients not undergoing bowel endometriosis ablation.
In our opinion, currently there are not sufficient data to affirm that discoid full-thickness resection of rectosigmoid endometriosis results in a lower pregnancy rate compared with segmental resection. Similar post-operative results in terms of pregnancy rate seem to offer to the surgeon an opportunity to freely choose between the two techniques, when indicated. To this end, we performed a case-control study between discoid and segmental resection confirming the role of discoid resection in small nodules (< 3 cm).
We hope that future prospective studies will be focused on endometriosis-related infertility and major surgery in order to provide answers to this enigmatic problem.
Francesco Fanfani, M.D.1
Anna Fagotti, M.D.1
Maria Lucia Gagliardi, M.D.1
Luca Minelli, M.D.2
Giovanni Scambia, M.D.1
1Department of Obstetrics and Gynecology
Catholic University of the Sacred Heart
2Department of Obstetrics and Gynecology
“Sacro Cuore” Hospital
1. Fanfani F, Fagotti A, Gagliardi ML, Ruffo G, Ceccaroni M, Scambia G, Minelli L. Discoid or segmental rectosigmoid resection for deep infiltrating endometriosis: a case-control study. Fertil Steril 2009;doi:10.1016/j.fertnstert.2009.03.066.
2. Mohr C, Nezhat FR, Nezhat CH, Seidman DS, Nezhat CR. Fertility consideration in laparoscopic treatment of infiltrative bowel endometriosis. J Sic Laparosc Surg 2005;9:16-24.
3. Ferrero S, Anaserini P, Abbamonte LH, Ragni N, Camerini G, Remorgida V. Fertility after bowel resection for endometriosis. Fertil Steril 2009;92:41-6.
4. Minelli L, Fanfani F, Fagotti A, Ruffo G, Ceccaroni M, Mereu L, Landi S, Pomini P, Scambia G. Laparoscopic colorectal resection for bowel endometriosis: fesibility, complications, and clinical outcome. Arch Surg 2009;144:234-9.
5. Remorgida V, Ragni N, Ferrero S, Anserini P, Torelli P, Fulcheri E. How complete is full thickness disc resection of bowel endometriosis lesions? A prospective surgical and histological study. Hum Reprod 2005;20:2317-20.
6. Stepniewska A, Pomini P, Bruni F, Mereu L, Ruffo G, Ceccaroni M, Scioscia M, Guerriero M, Minelli L. Laparoscopic treatment of bowel endometriosis in infertile women. Hum Reprod 2009;24:1619-25.
Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2009.10.056