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РЕПРОДУКТИВНОГО
ЗДОРОВЬЯ
И
УРО
-
НЕФРОЛОГИЧЕСКИХ
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| JOURNAL OF REPRODUCTIVE HEALTH AND URO-NEPHROLOGY RESEARCH
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УДК
:618.177:618.145+618.11-006-089
Ashurova Umida Alisherovna
Doctor of Philosophy,
Republican Specialized Scientific and Practical Medical Center
for Obstetrics and Gynecology,
Tashkent, Uzbekistan
Abdullayeva Lola Mirzatullayevna
Doctor of medical science,
Republican Specialized Scientific and Practical Medical Center
for Obstetrics and Gynecology,
Tashkent, Uzbekistan
Klychev Spartak Ilhomovich
Doctor of Medical Sciences, Professor
Republican Specialized Scientific and Practical Medical Center
for Obstetrics and Gynecology,
Tashkent, Uzbekistan
Ahmedova Aziza Tairovna
Assistant at Samarkand State Medical Institute
Departments of Obstetrics and Gynecology,
of the Faculty of Postgraduate Education,
Samarkand, Uzbekistan.
SURGICAL APPROACH TO THE TREATMENT OF ENDOMETRIOID OVARIAN CYSTS IN PATIENT WITH INFERTILITY:
«FOR» AND «AGAINST» (REVIEW)
For citation:
Ashurova Umida Alisherovna, Abdullayeva Lola Mirzatullayevna, Klychev Spartak Ilhomovich, Ahmedova Aziza Tairovna,
Surgical approach to the treatment of endometrioid ovarian cysts in patient with infertility: «for» and «against» (review), Journal of reproductive
health and uro-nephrology research. 2020, vol. 1, issue 1, pp.
http://dx.doi.org/10.26739/2181-0990-2020-1-7
Ашурова
Умида
Алишеровна
Доктор
философских
наук
,
Республиканского
специализированного
научно
-
практического
медицинского
центра
Акушерства
и
гинекологии
,
Ташкент
,
Узбекистан
Абдуллаева
Лола
Мирзатуллаевна
Доктор
медицинских
наук
,
Республиканского
специализированного
научно
-
практического
медицинского
центра
Акушерства
и
гинекологии
,
Ташкент
,
Узбекистан
Клычев
Спартак
Ильхомович
Доктор
медицинских
наук
,
профессор
Республиканского
специализированного
научно
-
практического
медицинского
центра
Акушерства
и
гинекологии
,
Ташкент
,
Узбекистан
Ахмедова
Азиза
Таировна
Ассистент
Самаркандского
Государственного
Медицинского
института
Кафедры
Акушерства
и
гинекологии
,
факультета
последипломного
образования
,
Самарканд
,
Узбекистан
.
ХИРУРГИЧЕСКИЙ
ПОДХОД
К
ЛЕЧЕНИЮ
ЭНДОМЕТРИОИДНЫХ
КИСТ
ЯИЧНИКОВ
У
ПАЦИЕНТОК
С
БЕСПЛОДИЕМ
:
«
ЗА
»
И
«
ПРОТИВ
» (
ОБЗОР
)
ЖУРНАЛ
РЕПРОДУКТИВНОГО
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Ashurova Umida Alisherovna
Falsafa fanlari doktori,
Respublika ixtisoslashtirilgan
akusherlik va ginekologiya ilmiy-amaliy tibbiyot markazi,
Toshkent, O'zbekiston
Abdullayeva Lola Mirzatullayevna
Tibbiyot fanlari doktori,
Respublika ixtisoslashtirilgan
akusherlik va ginekologiya ilmiy-amaliy tibbiyot markazi,
Toshkent, O'zbekiston
Klychev Spartak Ilhomovich
Tibbiyot fanlari doktori, professor
Respublika ixtisoslashtirilgan a
kusherlik va ginekologiya ilmiy-amaliy tibbiyot markazi,
Toshkent, O'zbekiston
Axmedova Aziza Tairovna
Samarqand davlat tibbiyot instituti assistenti
Akusherlik va ginekologiya kafedrasi,
Diplomdan keyingi ta'lim fakulteti,
Samarqand, O'zbekiston.
BEPUSHT AYOLLARDA TUXUMDON ENDOMETRIOID KISTALARINI JARROXLIK DAVOSINING O’RNI (ADABIYOTLAR
TAHLILI)
Despite a fairly detailed study of ovarian neoplasms, the
causes of benign tumors and ovarian cysts, and, consequently, the
issues of early diagnosis and prevention of the most common ovarian
neoplasms remain open [1,5].
According to foreign authors, surface-epithelial tumors account for
88.7% of all ovarian tumors, of which serous - 68.7%, mucinous -
8.5%, endometrioid - 6.5%, etc. [14].
Risk factors for ovarian tumors are: early menarche, late
menopause, menstrual dysfunction, high-calorie diets with a high
content of saturated fatty acids, genetic predisposition, infertility,
especially hormonal, stimulating therapy, chronic inflammatory
diseases of the uterus, smoking, etc. [2]., of a very different nature are
found at almost any age of women - from childhood to senile age [1].
With the onset of sexual activity, the clinical picture of benign ovarian
formations is supplemented by a complaint of infertility, which is
caused not only by hormonal disorders in the ovaries, but also by the
presence of a volumetric formation that compresses the cortical
substance and disrupts follicle maturation [8]. Previous studies have
shown that often only the removal of education by laparoscopy leads
to the restoration of fertility [2,3].
It is known that endometriosis affects 6 to 10% of women of
reproductive age, and among women with infertility occurs in 25-50%
of the population [7]. At the same time, in 17–44% of women
suffering from endometriosis, endometrioid ovarian cysts (ECY) are
detected, which are often combined with tubal infertility [18]. The
management of such patients is a complex and urgent, but not solved
problem in the world
On the issue of changes in the ovarian reserve after surgical
treatment of ECY, the inconsistency of the literature [6] attracts
attention. Thus, according to the results of two prospective cohort
studies, a progressive decrease in the ovarian reserve after surgical
treatment was revealed, whereas data from earlier studies indicate a
partial restoration of the reserve characteristics 3 months after the
operation [5]. According to studies by P. Santulli et al. (2016), ECJ is
not directly associated with a high risk of infertility, while a history of
surgical treatment of endometriosis has turned out to be a significant
risk factor for its development. It was shown that repeated surgical
removal of recurring ECJ can lead to a more pronounced decrease in
ovarian reserve compared with the first operation, and with bilateral
endometriomas it is associated with the risk of developing exhausted
ovary syndrome, often observed immediately after surgery [14].
The goal of surgical treatment of patients with infertility
associated with endometriosis is to restore the correct anatomy while
maintaining the function of the pelvic organs [17]. Moreover,
according to some authors, surgical treatment instead of expectant
tactics also allows you to increase the frequency of spontaneous
pregnancy. Surgical treatment of ECJ is the most common method
today (82.2%), however, some authors are inclined to believe that
removal of the cyst can damage healthy ovarian tissue and thereby
reduce ovarian reserve [12].
P. Vercellini et al. (2014) conducted a large-scale meta-
analysis of uncontrolled studies, including a series of cases, according
to which the pregnancy rate after surgical treatment of endometriosis
was 50%. It should be noted that with a combination of infertility
associated with endometriosis and pain, surgical treatment is the
optimal approach, the use of which allows you to both get rid of pelvic
pain and improve fertility rates [12].
In the case of an unsatisfactory ultrasound picture or with rapidly
growing ovarian cysts, surgical treatment should be considered
mandatory with the aim of obtaining tissue for subsequent histological
examination and excluding possible malignancy [1-5].
The question of the possibility in the preoperative period to
determine the nature of the ovarian tumor and to solve the question of
the volume and type (laparotomy or laparoscopy) of the operation is
still controversial [3]. Not all gynecological hospitals have a
morphological laboratory for intraoperative rapid diagnosis of a tumor
capsule, which allows you to reasonably choose the operative tactics
[1-3].
A large number of scientific studies have been devoted to
improving methods for diagnosing ovarian tumors. The main
development was received by radiation, immunological research
methods, diagnostic laparoscopy. Informative are the ultrasound
examination of the pelvic organs in the abdominal and transvaginal
ways [18,19].
Russian oncologists consider any ovarian formation to be
potentially malignant, which implies a wide range of examinations in
the preoperative period, histological verification of the diagnosis and,
if necessary, radical surgery. The choice of surgical tactics for the
treatment of such tumors is affected by age, the reproductive status of
women, and the histotype of education. It is this circumstance that
causes the problem of the choice of therapeutic tactics when detecting
ovarian cysts, especially in patients with infertility [1,4].
The problem of benign ovarian tumors (DOY) is important not
only because of their high prevalence, but also in connection with the
widespread use of modern minimally invasive surgical treatment by
laparoscopy. However, the likelihood of recurrence and malignancy of
ovarian formations or contamination of the abdominal cavity when the
tumor is removed in the case of an undiagnosed malignant formation is
also an urgent problem [10].
ЖУРНАЛ
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DOIA develop in women of any age in 48-64.5% of cases, but
more often in the reproductive period. Due to the increase in the
structure of diseases in women of reproductive age, the proportion of
retention or tumor-like formations of the ovaries (OOI), DOG, as well
as polycystic ovary syndrome, chronic anovulation, which
significantly affect the reproductive function of patients characterized
by infertility, the problem has social significance [9,10 ].
About 80% of patients with malignant ovarian formations
enter a hospital with common stages of the disease, and this leads to
low treatment efficiency and high mortality [1,6,7]. Consequently, the
question remains not only of identifying or detecting ovarian
formation, but also predicting its nature, i.e. to determine before
surgery the malignant, borderline or benign this formation to address
the issue of the most optimal access (laparoscopy or laparotomy) [8].
Nevertheless, even in carefully examined patients with ECU-
specific ultrasound, the malignant process is detected in 0.9% of cases.
The presence of ECJ directly leads to structural changes in the ovarian
tissue, which can complicate the collection of oocytes due to both the
size and location of the cyst, and the accompanying adhesive process
[10,14,15]. In this case, of course, prior surgical removal of cysts is
required in order to provide access to the follicles.
The advantages of surgical treatment of ECJ include reducing
the severity of pain, preventing cyst rupture, providing access to the
follicles and taking oocytes for use in ART. Surgical treatment allows
to assess the degree of involvement of the fallopian tubes in the local
adhesion process [12]. In addition, a histopathological examination
allows you to detect signs of malignancy in the tissue of a distant
formation. The question of the ideal method of surgical treatment
remains debatable and debated: what should be done - completely
remove the cyst with excision of the capsule or conduct drainage
followed by ablation of the cyst capsule [15].
It is believed that indications for surgical treatment in young
patients should be limited in the absence of severe pelvic pain. In this
case, it is necessary to explain to the woman the possible risks of a
decrease in ovarian function after surgical treatment. For patients of
reproductive age with ovarian operations in the anamnesis at the first
stage, it is necessary to evaluate the ovarian reserve.
For patients of reproductive age with ovarian operations in the
anamnesis at the first stage, it is necessary to evaluate the ovarian
reserve. In those cases where the likelihood of spontaneous conception
is small, it is necessary to consider the possibility of using ART
[13,16]. Some experts argue that endometriomas larger than 3 cm
require surgical removal at the stage of preparation for ART, while
others, on the contrary, believe that due to a possible reduction in the
ovarian reserve during surgery, surgical treatment should be abstained
[18].
In a prospective randomized clinical trial, A. Demirol et al.
(2016) it was shown that surgical removal of ECY before IVF leads to
a decrease in the ovarian response in ART cycles. As the results of
histological studies of the removed material showed, during the
operation, along with the capsule, healthy ovarian tissue was
inadvertently excised, which explains the subsequent decrease in
ovarian reserve.
Excessive bipolar coagulation also damages healthy ovarian tissue.
Results of a report by I. Streuli et al. (2012) suggest that endometrioma
alone does not reduce the ovarian response, which was assessed by
AMH. The decrease in ovarian response in patients with ECY is
iatrogenic in nature and is the result of surgical removal of the cyst. In
accordance with the results of these studies, the latest
recommendations suggest abstaining from surgical treatment of ECY
until ART is performed.
Thus, after analyzing the literature data, it can be concluded
that: endometrioma is one of the main clinical forms of endometriosis,
often combined with infertility; ECYs contain high concentrations of
biologically active substances (proteolytic enzymes and inflammatory
mediators), which contributes to the structural disorganization of the
inner part of the ovarian cortex; high is the frequency of the
combination of ECY with tubal infertility; in patients with infertility
associated with endometriosis, the goal of surgical treatment should be
to restore the correct anatomy while maintaining the functions of the
pelvic organs; surgical treatment can reduce the severity of pain,
prevent cyst rupture and subsequent infection, intraoperatively
evaluate the ovarian reserve by counting, allowing to predict the
possibility of pregnancy after surgical treatment, to facilitate the
collection of eggs for the purpose of using ART, to assess the degree
of involvement of the fallopian tubes in the local adhesion process, to
detect signs of malignancy in tissue of a distant formation during
histopathological examination; the decision to perform surgical
intervention should be carefully weighed and made taking into account
the possible reduction in ovarian reserve as a result of the operation
[11-16].
Debatable and controversial are the information: that the surgical
removal of ECYA has a negative effect on the ovarian reserve;
changes in the ovarian reserve after surgical treatment of ECJ (along
with its decrease after surgical treatment, a partial restoration of
characteristics after the operation is also shown); that the presence of
ECJ is not directly associated with a high risk of infertility, while
surgical treatment of endometriosis is a significant risk factor for the
development of infertility; that surgical treatment instead of expectant
tactics also allows you to increase the frequency of spontaneous
pregnancy; about the need to remove ECY before the planned IVF;
that with a combination of infertility associated with endometriosis
and pain, surgical treatment is the only correct approach that allows
you to get rid of pelvic pain and directly affects fertility rates; about
the ideal method of surgical treatment: complete removal with
excision of the cyst capsule or drainage and subsequent ablation of the
cyst capsule; that in relation to patients, previously operated on for
endometriosis, with reduced ovarian reserve, with no pain and cyst
growth, ART should be considered as first-line therapy to reduce the
time of pregnancy [7-10].
All this makes it necessary to conduct research aimed at
improving the choice of therapeutic tactics for the detection of ECJ in
patients suffering from infertility [13].
It is necessary to further study the effect of ECJ on
physiological processes in the tissues of the ovary, determining the
role of ECJ and surgical treatment of cysts in reducing the ovarian
reserve and the likelihood of spontaneous pregnancy and further
outcomes [15].
Literature:
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fertilization cycles // Fertil Steril. 2014 -
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8(1). –
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2. Bezhenar V.F., Yarmolinskaya M.I. Comparison of the effectiveness of various schemes of hormone-modulating therapy after surgical
treatment of external genital endometriosis // Problemy reproduktsii. 2015. -
№
(4).
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89–98. Russian.
3. Brink Laursen J., Schroll J.B., Macklon K.T. et al. Surgery versus conservative management of endometriomas in subfertile women. A
systematic review // Acta Obstet. Gynecol. Scand. 2017. - Vol. 96. - P. 727–735.
4. Carrillo, L. et al. The Role of Fertility Preservation in Patients with Endometriosis // Journal of Assisted Reproduction and Genetics. 2017. -
P. 317–323.
5. Dunselman G.A., Vermeulen N., Becker C. et al. ESHRE guideline: management of women with endometriosis // Hum. Reprod. 2014. - Vol.
29, N 3. - P. 400–412.
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6. Garavaglia, Elisabetta et al. Fertility Preservation in Endometriosis Patients: Anti-Müllerian Hormone Is a Reliable Marker of the Ovarian
Follicle Density // Frontiers in Surgery. 2017. -
№
40. - P. 286 - 293.
7. Goud PT, Goud AP, Joshi N, Puscheck E, Diamond MP, Abu-Soud HM. Dynamics of nitric oxide, altered follicular microenvironment and
oocyte quality in women with endometriosis. // Fertil Steril. 2014. – Vol.102(1). -P 151-9.
8. Jain G, Khatuja R, Juneja A, Mehta S. Laparoscopy: as a first line diagnostic tool for infertility evaluation // J Clin Diagn Res. 2014. –
Vol.8(10). - P:01-02.
9. Kwon SK, Kim SK, Yun SC, Kim DY, Chae HD, Kim CH, et al. Decline of serum antimüllerian hormone levels after laparoscopic ovarian
cystectomy in endometrioma and other benign cysts: a prospective cohort study // Fertil Steril. 2014. – Vol.101(2). – P. 435-41.
10. Muzii L., Tucci C.D., Feliciantonio M.D. et al. Infertility associated with ovarian endometriomas: surgery or in-vitro fertilization? // J. In
Vitro Fertilization. 2017. - Vol. 1, N 1. - P. 1–3.
11. Muzii L., Tucci C.D., Feliciantonio M.D. et al. Management of endometriomas // Semin. Reprod. Med. 2017. - Vol. 35. - P. 25–30.
12. Ovarian Endometrioma: What the Patient Needs / Endometriosis Treatment Italian Club // J. Minim. Invasive Gynecol. – 2014. – Vol. 21,
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13. Ovarian Endometrioma: What the Patient Needs / Endometriosis Treatment Italian Club // J.Minim. Invasive Gynecol. – 2014. – Vol. 21,
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