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ORIGINAL ARTICLES-G

VOL. 74 ● NUMBER 1 ● January-February  2024
ORIGINAL ARTICLES-G

Efficacy of Ethanol Sclerotherapy Versus Laparoscopic Excision in the Treatment of Ovarian Endometrioma

Samaneh Mohtashami1 · Masoome Jabarpour2 · Ashraf Aleyasin1,3 · Marzieh Aghahosseini1,3 · Ayda Najafian1,3

Samaneh Mohtashami, MD, Gynecologist; Masoome Jabarpour, Phd, Embryologist; Ashraf Aleyasin, MD, Gynecologist, Infertility Fellowship, Professor; Marzieh Aghahosseini, MD, Gynecologist, Infertility Fellowship, Professor; Ayda Najafian, MD, Gynecologist, Infertility Fellowship, Assistant Professor.

Ayda Najafian

anajafian@sina.tums.ac.ir

1 Department of Obstetrics and Gynecology, Shariati Hospital, Tehran University of Medical Sciences, Jalal‑E‑Al‑E‑Ahmad Hwy, Tehran 1411713135, Iran

2 Department of Anatomy, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran

3 Department of Infertility, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran

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Objective The purpose of this study was to examine the recurrence rates of ovarian endometrioma, dysmenorrhea, dyspareunia, and related complications between sclerotherapy and laparoscopic ovarian cystectomy in individuals aged 25 to 38.

Methods Eighty-eight women participated in this retrospective, single-center study between January 2020 and February 2022. Patients received either laparoscopy or sclerotherapy, depending on the opinion of the pertinent physician. In this study, the following parameters were retrospectively analyzed in follow-up visits 2, 6 and 12 months after sclerotherapy and laparoscopy: dysmenorrhea and dyspareunia by visual analog scale, complications following the intervention, and serial pelvic sonograms for endometrioma cyst recurrence. Moreover, serum Anti-Müllerian hormone (AMH) level before and 6 months after sclerotherapy/surgery were analyzed. The collected data were then analyzed using R software.

Results The results demonstrate the efficiency of both sclerotherapy and laparoscopic techniques in reducing endometrioma- related dysmenorrhea and dyspareunia over a 12-month period. There was no statistically significant difference in the occurrence of complications and recurrence rate between these two therapies, and both are equally beneficial. Also, the rate of AMH decline after laparoscopy was higher than sclerotherapy; however there was not a statistically significant change in serum level of AMH in laparoscopy compared to the sclerotherapy after 6 months.

Conclusion Considering all the data, it appears that sclerotherapy, with its lower cost, shorter hospital stay, and quicker return to activities, can be a laparoscopic alternative to endometrioma cyst removal. More studies are required.

Keywords : Endometrioma · Sclerotherapy · Laparoscopy · Dysmenorrhea · Dyspareunia

Endometriosis is a prevalent disorder that affects around 10 percent of women in the reproductive age group all over the world. During this condition, endometrial tissue is present outside the uterus in places such as the ovaries, peritoneum, and intestines [1]. Chronic pelvic pain and infertility are connected with this condition. The most frequently mentioned symptoms are dysmenorrhea and dyspareunia [2]. Endometriosis patients who also have ovarian endometrioma (OMA) make up 17 to 44% of all patients with endometriosis [3]. According to the updated American Society for Reproductive Medicine (ASRM) classification, OMAs are found in patients with advanced disease stages [4]; nonetheless, their cause and management remain controversial. Regardless of its size, endometrioma can cause ovarian injury by mechanical straining. As it contains inflammatory factors, proteolytic enzymes, and degrading agents, its substance induces metaplasia and fibrosis and lowers the number of cortical-specific

stromal cells [4, 5]. Despite the considerable frequency of endometriosis, gynecologists have always debated a treatment that could increase fertility, relieve pain, and prevent the disease's recurrence. Laparoscopic cystectomy is the treatment of choice for endometriomas, with documented recurrence rates ranging from 5 to 66.7% [6]. However, the loss of neighboring healthy ovarian tissue by ovarian cystectomy may result in a diminished ovarian reserve[7]. It's also been found that 2.6% of women experience premature ovarian failure and menopause after undergoing bilateral ovarian cystectomy (to remove an endometrioma)[8]. Other less invasive methods must be developed in order to avoid postoperative complications and minimize the impact on fertility. Ethanol sclerotherapy [9] is an alternate method for preserving ovarian reserve. Sclerotherapy with ethanol has been used in various organs for a long (such as thyroid, liver, kidney, and spleen). In 1988, Akamatsu et al. used ethanol to treat endometriomas for the first time [10]. This minimally invasive method removed the cyst by disrupting the epithelial lining of the cyst, resulting in inflammation and fibrosis [11]. Sclerotherapy following aspiration was found to be more effective than aspiration alone in terms of recurrence (8 to 14.9 percent and 83.3 percent, respectively) [12, 13]. The reported recurrence rates following sclerotherapy, after 12 to 24 months of follow-up, vary from 0 to 62.5%, depending on the procedure employed [10, 14, 15]. This conservative approach may be effective in alleviating symptoms while also saving money. Endometriosis is accompanied by dysmenorrhea, dyspareunia, pelvic pain, and infertility. Endometriosis is the most prevalent cause of secondary dysmenorrhea, which has a detrimental influence on an individual's quality of life and productivity. Endometriosis-related dysmenorrhea is treated with antiinflammatory drugs, GnRH agonists, danazol, and surgery.

Each strategy offers benefits and drawbacks that can be utilized based on the patient's situation [16]. The purpose of this retrospective study was to investigate the degree of pain (dysmenorrheal and dyspareunia), the rate of recurrence of OMA, serum AMH level and related complications following sclerotherapy vs. laparoscopic ovarian cystectomy in patients aged 25–38 years.

Declarations
Conflict of interest The authors declare that they have no conflicts of interest.

Consent for Publication Not applicable.

Ethics Approval and Consent to Participate The Ethics Committee of Tehran University of Medical Sciences approved this retrospective study, and the ethical approval code was IR.TUMS.MEDICINE REC.1401.048. Informed consent was obtained from all individual participants included in the study.

  1. Zondervan K, Becker C, Koga K, Missmer S, Taylor R, Vigano P. Endometriosis. Nat Rev Dis Primers. 2018;4:9. https:// doi. org/ 10. 1038/ s41572- 018- 0008-5 
  2. Vercellini P, Viganò P, Somigliana E, Fedele L. Endometriosis: pathogenesis and treatment. Nat Rev Endocrinol. 2014;10(5):261– 275.https:// doi. org/ 10. 1038/ s41572- 018- 0008-5 
  3. Redwine DB. Ovarian endometriosis: a marker for more extensive pelvic and intestinal disease. Fertil Steril. 1999;72(2):310–315. https:// doi. org/ 10. 1016/ s0015- 0282(99) 00211-3
  4. ASRM. Revised American society for reproductive medicine classification of endometriosis: 1996. Fertil Steril. 1997;67(5):817– 821. https:// doi. org/ 10. 1016/ s0015- 0282(97) 81391-x 
  5. Sanchez A, Viganò P, Somigliana E, Panina-Bordignon P, Vercellini P, Candiani M. The distinguishing cellular and molecular features of the endometriotic ovarian cyst: from pathophysiology to the potential endometrioma-mediated damage to the ovary. Hum Reprod Update. 2014;20(2):217–230.https:// doi. org/ 10. 1093/ humupd/ dmt053 
  6. De Cicco NA, Carfagna P, De Cicco NC, Scambia G, Marana R, De Cicco NF. Laparoscopic ethanol sclerotherapy for ovarian endometriomas: preliminary results. J Minim Invasive Gynecol. 2020;27(6):1331–6. https:// doi. org/ 10. 1016/j. jmig. 2019. 09. 792.
  7. Biacchiardi CP, Delle Piane L, Camanni M, Deltetto F, Delpiano EM, Marchino GL, et al. Laparoscopic stripping of endometriomas negatively affects ovarian follicular reserve even if performed by experienced surgeons. Reprod Biomed Online. 2011;23(6):740–6. https:// doi. org/ 10. 1016/j. rbmo. 2011. 07. 014. 
  8. Dicker D, Goldman JA, Feldberg D, Ashkenazi J, Levy T. Transvaginal ultrasonic needle-guided aspiration of endometriotic cysts before ovulation induction for in vitro fertilization. J Vitro Fert Embryo Transf. 1991;8(5):286–9. https:// doi. org/ 10. 1007/ BF011 39786. 
  9. Cohen A, Almog B, Tulandi T. Sclerotherapy in the management of ovarian endometrioma: systematic review and meta-analysis. Fertil Steril. 2017;108(1):117–124. e115. https:// doi. org/ 10. 1016/j. fertn stert. 2017. 05. 015
  10. Akamatsu N, Hirai T, Masaoka H, Sekiba K, Fujita T. Ultrasonically guided puncture of endometrial cysts–aspiration of contents and infusion of ethanol. Nihon Sanka Fujinka Gakkai Zasshi. 1988;40(2):187–91 (PMID: 3283269). 
  11. Albanese G, Kondo KL, editors. Pharmacology of sclerotherapy. Seminars in interventional radiology; 2010: © Thieme Medical Publishers. https:// doi. org/ 10. 1055/s- 0030- 12678 48 
  12. Noma J, Yoshida N. Efficacy of ethanol sclerotherapy for ovarian endometriomas. Int J Gynecol Obstet. 2001;72(1):35–39. https:// doi. org/ 10. 1016/ s0020- 7292(00) 00307-6
  13.  Hsieh C-L, Shiau C-S, Lo L-M, Chang M-Y. Effectiveness of ultrasound-guided aspiration and sclerotherapy with 95% ethanol for treatment of recurrent ovarian endometriomas. Fertil Steril. 2009;91(6):2709–13. https:// doi. org/ 10. 1016/j. fertn stert. 2008. 03. 056.
  14. García-Tejedor A, Castellarnau M, Ponce J, Fernández ME, Burdio F. Ethanol sclerotherapy of ovarian endometrioma: a safe and effective minimal invasive procedure. Preliminary Results Eur J Obstet Gynecol. 2015;187:25–9. https:// doi. org/ 10. 1016/j. ejogrb. 2015. 02. 004. 
  15. Garcia-Tejedor A, Martinez-Garcia JM, Candas B, Suarez E, Mañalich L, Gomez M, et al. Ethanol sclerotherapy versus laparoscopic surgery for endometrioma treatment: a prospective, multicenter, cohort pilot study. J Minim Invasive Gynecol. 2020;27(5):1133–1140. https:// doi. org/ 10. 1016/j. jmig. 2019. 08. 036
  16. Taylor HS, Pal L, Sell E. Speroff's clinical gynecologic endocrinology and infertility: Lippincott Williams & Wilkins; 2019. ISBN: 978–1–4511–8976–6 
  17. Li X-Y, Chao X-P, Leng J-H, Zhang W, Zhang J-J, Dai Y, et al. Risk factors for postoperative recurrence of ovarian endometriosis: long-term follow-up of 358 women. J Ovarian Res. 2019;12(1):1–10.https:// doi. org/ 10. 1186/ s13048- 019- 0552-y
  18. Deckers P, Ribeiro SC, Simoes RDS, Miyahara C, Baracat EC. Systematic review and meta-analysis of the effect of bipolar electrocoagulation during laparoscopic ovarian endometrioma stripping on ovarian reserve. Int J Gynecol Obstet. 2017;140(1):11–17. https:// doi. org/ 10. 1002/ ijgo. 12338
  19. Koga K, Takemura Y, Osuga Y, Yoshino O, Hirota Y, Hirata T, et al. Recurrence of ovarian endometrioma after laparoscopic excision. Hum Reprod. 2006;21(8):2171–4. https:// doi. org/ 10. 1093/ humrep/ del125. 
  20. Liu X, Yuan L, Shen F, Zhu Z, Jiang H, Guo S-W. Patterns of and risk factors for recurrence in women with ovarian endometriomas. Obstet Gynecol. 2007;109(6):1411–1420. https:// doi. org/ 10. 1097/ 01. AOG. 00002 65215. 87717. 8b 
  21. Raffi F, Metwally M, Amer S. The impact of excision of ovarian endometrioma on ovarian reserve: a systematic review and metaanalysis. J Clin Endocrinol Metab. 2012;97(9):3146–54. https:// doi. org/ 10. 1210/ jc. 2012- 1558.
  22. Coccia ME, Rizzello F, Cammilli F, Bracco GL, Scarselli G. Endometriosis and infertility: surgery and ART: an integrated approach for successful management. Eur J Obstet Gynecol. 2008;138(1):54–9. https:// doi. org/ 10. 1016/j. ejogrb. 2007. 11. 010. 
  23. Esinler I, Bozdag G, Aybar F, Bayar U, Yarali H. Outcome of in vitro fertilization/intracytoplasmic sperm injection after laparoscopic cystectomy for endometriomas. Fertil Steril. 2006;85(6):1730–1735. https:// doi. org/ 10. 1016/j. fertn stert. 2005. 10. 076 
  24. Aflatoonian A, Rahmani E, Rahsepar M. Assessing the efficacy of aspiration and ethanol injection in recurrent endometrioma before IVF cycle: a randomized clinical trial. Iran J Reprod Med. 2013;11(3):179. PMCID: PMC3943218 
  25. Wang L-L, Dong X-Q, Shao X-H, Wang S-M. Ultrasound-guided interventional therapy for recurrent ovarian chocolate cysts. Ultrasound Med Biol. 2011;37(10):1596–1602. https:// doi. org/ 10. 1016/j. ultra smedb io. 2011. 07. 004
  26. Ikuta A, Tanaka Y, Mizokami T, Tsutsumi A, Sato M, Tanaka M, et al. Management of transvaginal ultrasound-guided absolute ethanol sclerotherapy for ovarian endometriotic cysts. J Med Ultrason. 2006;33(2):99–103. https:// doi. org/ 10. 1007/ s10396- 005- 0079-2. 
  27. Agostini A, De Lapparent T, Collette E, Capelle M, Cravello L, Blanc B. In situ methotrexate injection for treatment of recurrent endometriotic cysts. Eur J Obstet Gynecol. 2007;130(1):129–31. https:// doi. org/ 10. 1016/j. ejogrb. 2006. 01. 015.
  28. Yazbeck C, Madelenat P, Ayel J, Jacquesson L, Bontoux L, Solal P, et al. Ethanol sclerotherapy: a treatment option for ovarian endometriomas before ovarian stimulation. Reprod Biomed Online. 2009;19(1):121–5. https:// doi. org/ 10. 1016/ s1472- 6483(10) 60055-7. 
  29. Alborzi S, Hosseini-Nohadani A, Poordast T, Shomali Z. Surgical outcomes of laparoscopic endometriosis surgery: A 6 year experience. Curr Med Res Opin. 2017;33(12):2229–2234. https:// doi. org/ 10. 1080/ 03007 995. 2017. 13623 77 
  30. Koga K, Osuga Y, Takemura Y, Takamura M, Taketani Y. Recurrence of endometrioma after laparoscopic excision and its prevention by medical management. Front Biosci (Elite Ed). 2013;5:676–683.https:// doi. org/ 10. 1093/ humrep/ del125 
  31. Seo J-W, Lee D-Y, Yoon B-K, Choi D. The age-related recurrence of endometrioma after conservative surgery. Eur J Obstet Gynecol. 2017;208:81–5. https:// doi. org/ 10. 1016/j. ejogrb. 2016. 11. 015.
  32. Celik HG, Dogan E, Okyay E, Ulukus C, Saatli B, Uysal S, et al. Effect of laparoscopic excision of endometriomas on ovarian reserve: serial changes in the serum antimüllerian hormone levels. Fertil Steril. 2012;97(6):1472–8. https:// doi. org/ 10. 1016/j. fertn stert. 2012. 03. 027. 
  33. Somigliana E, Berlanda N, Benaglia L, Viganò P, Vercellini P, Fedele L. Surgical excision of endometriomas and ovarian reserve: a systematic review on serum antimüllerian hormone level modifications. Fertil Steril. 2012;98(6):1531–1538. https:// doi. org/ 10. 1016/j. fertn stert. 2012. 08. 009 
  34. Martinez-Garcia JM, Candas B, Suarez-Salvador E, Gomez M, Merino E, Castellarnau M, et al. Comparing the effects of alcohol sclerotherapy with those of surgery on anti-Müllerian hormone and ovarian reserve after endometrioma treatment. A prospective multicenter pilot cohort study. Eur J Obstet Gynecol. 2021;259:60–66. https:// doi. org/ 10. 1016/j. ejogrb. 2021. 01. 027 
  35. Han K, Seo SK, Kim M-D, Kim GM, Kwon JH, Kim HJ, et al. Catheter-directed sclerotherapy for ovarian endometrioma: shortterm outcomes. Radiology. 2018;289(3):854–859 https:// doi. org/ 10. 1148/ radiol. 20181 80606 
  36. Vignali M, Mabrouk M, Ciocca E, Alabiso G, Barbasetti di Prun A, Gentilini D, et al. Surgical excision of ovarian endometriomas: Does it truly impair ovarian reserve? Long term anti‐Müllerian hormone (AMH) changes after surgery. Journal of Obstetrics and Gynaecology Research. 2015;41(11):1773–1778. https:// doi. org/ 10. 1111/ jog. 12830
  37. Lee JK, Ahn SH, Kim HI, Lee YJ, Kim S, Han K, et al. Therapeutic efficacy of catheter-directed ethanol sclerotherapy and its impact on ovarian reserve in patients with ovarian endometrioma at risk of decreased ovarian reserve: a preliminary study. J Minim Invasive Gynecol. 2022;29(2):317–23. https:// doi. org/ 10. 1016/j. jmig. 2021. 08. 018.
  38. Miranda CS, Carvajal AR. Complications of operative gynecological laparoscopy. JSLS. 2003;7(1):53 (PMID: 12722999). 
  39. Alborzi S, Askary E, Keramati P, Moradi Alamdarloo S, Poordast T, Ashraf MA, et al. Assisted reproductive technique outcomes in patients with endometrioma undergoing sclerotherapy vs laparoscopic cystectomy: Prospective cross‐sectional study. Reprod Med Biol. 2021;20(3):313–320. https:// doi. org/ 10. 1002/ rmb2. 12386
  40. Koo JH, Lee I, Han K, Seo SK, Kim M-D, Lee JK, et al. Comparison of the therapeutic efficacy and ovarian reserve between catheter-directed sclerotherapy and surgical excision for ovarian endometrioma. Eur Radiol. 2021;31(1):543–8. https:// doi. org/ 10. 1007/ s00330- 020- 07111-1.
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