title: Adenomyosis and reproductive performance after surgery for rectovaginal and colorectal endometriosis: a systematic review and meta-analysis.
abstract: The relationship between rectovaginal-bowel endometriosis and fertility is unclear. Nevertheless, extirpative surgery, including colorectal resection, is being fostered as a fertility-enhancing procedure. Adenomyosis and deep endometriosis often coexist. As the uterine condition may further impact on reproductive outcome, this work performed a systematic literature review with the objective of identifying all English-language reports on surgical treatment for rectovaginal and colorectal endometriosis, including bowel resection, in which participants were screened preoperatively for uterine adenomyosis. Risk ratios (RR) were then combined in a meta-analysis. In the five selected observational studies, in women seeking pregnancy, 7/59 (11.9%) with concomitant adenomyosis conceived, compared with 74/172 (43.0%) in those without adenomyosis. Adenomyosis was never excised. One in 10 women experienced a major surgical complication. The RR of clinical pregnancy ranged from 0.23 to 0.46, with absence of heterogeneity among studies (I(2)=0.0%). Pooling of the results yielded a common RR of 0.32 (95% confidence interval 0.16 to 0.66). No small-study effect was detected (Egger's test). Screening for adenomyosis before suggesting difficult and risky procedures may allow identification of a subgroup of patients at particularly worse prognosis for which surgery would have a marginal effect on the likelihood of conception. Deep endometriosis may infiltrate the rectum, vagina and sigmoid colon. These severe forms are usually associated with pain, but their relationship with fertility is unclear. Despite lack of convincing evidence, extirpative surgery, including colorectal resection, is being fostered as a fertility-enhancing procedure, although these procedures may cause major complications. Adenomyosis (i.e. the infiltration of the uterine wall by endometrial glands) often coexists with deep endometriosis, and several investigators believe that the former condition may have a detrimental effect on fertility more than the latter. If this is true, screening for adenomyosis may allow preoperative identification of a subgroup of patients at particularly worse prognosis for whom difficult and risky surgery would have a marginal or no effect on the likelihood of conception. To disentangle this issue, we performed a systematic literature review with the objective of identifying all English-language reports on surgical treatment for rectovaginal and colorectal endometriosis, including bowel resection, in which participants were also investigated preoperatively for uterine adenomyosis. Risk ratios (RR) were then combined in a meta-analysis. In the five selected observational studies, in women seeking pregnancy, 7/59 (11.9%) women with concomitant adenomyosis conceived, compared with 74/172 (43.0%) in those without adenomyosis. One in 10 women experienced a major surgical complication. The RR of clinical pregnancy consistently ranged from 0.23 to 0.46. Pooling of the results yielded a common RR of 0.32 (95% CI 0.16-0.66). Adenomyosis was associated with a 68% reduction in the likelihood of pregnancy in women seeking conception after surgery for rectovaginal and colorectal endometriosis.
authors.affiliation: Department of Clinical Sciences and Community Health, Università degli Studi di Milano, and Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, 20122 Milan, Italy; Center for Research in Obstetrics and Gynaecology (C.R.O.G.), 20122 Milan, Italy. Electronic address: paolo.vercellini@unimi.it.
authors.forename: Paolo
authors.initials: P
authors.lastname: Vercellini
authors.affiliation: Epidemiology Unit, Department of Preventive Medicine, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, 20122 Milano, Italy.
authors.forename: Dario
authors.initials: D
authors.lastname: Consonni
authors.affiliation: Department of Clinical Sciences and Community Health, Università degli Studi di Milano, and Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, 20122 Milan, Italy.
authors.forename: Giussy
authors.initials: G
authors.lastname: Barbara
authors.affiliation: Department of Clinical Sciences and Community Health, Università degli Studi di Milano, and Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, 20122 Milan, Italy.
authors.forename: Laura
authors.initials: L
authors.lastname: Buggio
authors.affiliation: Department of Clinical Sciences and Community Health, Università degli Studi di Milano, and Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, 20122 Milan, Italy; Center for Research in Obstetrics and Gynaecology (C.R.O.G.), 20122 Milan, Italy.
authors.forename: Maria Pina
authors.initials: MP
authors.lastname: Frattaruolo
authors.affiliation: Center for Research in Obstetrics and Gynaecology (C.R.O.G.), 20122 Milan, Italy; Infertility Unit, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, 20122 Milan, Italy.
authors.forename: Edgardo
authors.initials: E
authors.lastname: Somigliana
mesh_terms: D062788:Adenomyosis / Q000473:pathology*; D004715:Endometriosis / Q000601:surgery*; D005260:Female; D006801:Humans; D007247:Infertility, Female / Q000601:surgery*; D011183:Postoperative Complications; D011247:Pregnancy; D018873:Pregnancy Rate; D011379:Prognosis; D012002:Rectal Diseases / Q000601:surgery*; D018570:Risk Assessment; D014623:Vaginal Diseases / Q000601:surgery*
keywords: adenomyosis; bowel endometriosis; infertility; rectovaginal endometriosis; surgery; systematic review