Improving fertility rates and symptoms for peritoneal endometriosis

For patients suffering from symptomatic early-stage endometriosis, a consistent excision of altered peritoneum followed by adjuvant hormonal therapy and multimodal concepts improves outcomes, particularly for pregnancy and recurrence rates.

This is the major finding of a German prospective study in the Archives of Gynecology and Obstetrics.

“Clinically managing endometriosis is a huge challenge,” said principal investigator Sylvia Mechsner, MD, head of the Endometriosis Centre Charité at Charité University Hospital in Berlin. “We need to find a good balance between conservative and surgical treatment.”

Sylvia Mechsner, MD

Mechsner has had success by starting with sufficient hormonal treatment like therapeutic amenorrhea, especially when no organ damage is suspected. “Many patients achieve good pain relief,” she said. “But when is surgery a better option?”

Ongoing pelvic pain while taking sufficient hormonal treatment is Mechsner’s No. 1 consideration for surgery. “I believe neurogenic inflammation is present in most lesion cases and can cause non-estrogen related pain,” she said. “This is acyclical pain, due to changes in the sensory and sympathetic nerve fiber composition/innervation.”

For the study, patients stopped hormonal treatment 2 months prior to surgery, consisting of a resection not only of the visible lesions, but of the inflamed altered surrounding tissue as well.

“Of course, infertility or seeking pregnancy are also indications for the surgery,” Mechsner told Contemporary OB/GYN. “We wanted to prove this concept and analyze the extension of inflammation in the excised tissue and the pain relief and fertility rate.”

The prospectively maintained database at the Endometriosis Centre Charité identified all symptomatic women with the suspicion of only peritoneal endometriosis who underwent laparoscopy from January 2014 to June 2019.

Laparoscopic peritonectomy was performed on 94 women, all by Mechsner. Follow-up data were available for 87% of the cases.

At the time of surgery, nearly all patients showed signs of stage I or II endometriosis: 44.7% and 48.9%, respectively.

Roughly 75% of the women reported pain relief due to the post-surgical hormonal therapy, with 25% completely pain free.

“It was unexpected, but made me happy, to see so many women achieve some pain relief,” Mechsner said. “However, in many of these cases, we found severe adenomyosis. And in cases of organ-sparing surgery, it is logical that uterus-associated pain could be persistent.”

Some patients also suffer from severe chronic pelvic pain syndrome with central sensitization, thus needing ongoing multimodal treatment like hormonal treatment, osteopathy, manual therapy, pelvic floor relaxing exercises, transcutaneous electrical nerve stimulation (TENS), pain management and psychological support.

The study found that 33% of women wanted to have children after the procedure, of whom 63% became pregnant, with the majority not requiring assisted reproductive therapy (ART).

Seven of the women had a reoperation.

Two limitations of the study are no control group and limited to a single center.

“I believe it is good to know that endometriosis-related pain should be treated conservatively, especially in cases when no organ damage is suspected,” Mechsner said. “It is also reassuring to know that there is no need to schedule surgery for diagnosis only because the study’s protocol confirmed the peritoneal lesions in 100% of women.”

But in cases of ongoing acyclical pelvic pain, “it appears that peritoneal lesions are the cause of the pain, for which surgery with destruction/excision is recommended,” she said.

Mechsner reports no relevant financial disclosures.

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Dückelmann AM, Taube E, Abesadze E, et al. When and how should peritoneal endometriosis be operated on in order to improve fertility rates and symptoms? The experience and outcomes of nearly 100 cases.

Arch Gynecol Obstet. Published online February 3, 2021.

doi:10.1007/s00404-021-05971-6